Provider Demographics
NPI:1700023488
Name:DESMOND, TIMOTHY AMBROSE (MA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:AMBROSE
Last Name:DESMOND
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4340
Mailing Address - Country:US
Mailing Address - Phone:510-452-2820
Mailing Address - Fax:
Practice Address - Street 1:303 VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4340
Practice Address - Country:US
Practice Address - Phone:510-452-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF-51287106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist