Provider Demographics
NPI:1710125232
Name:THEIN, TIMOTHY A (LCSW, CAP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:THEIN
Suffix:
Gender:M
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5390
Mailing Address - Country:US
Mailing Address - Phone:321-421-6992
Mailing Address - Fax:321-421-6993
Practice Address - Street 1:1301 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5390
Practice Address - Country:US
Practice Address - Phone:321-421-6992
Practice Address - Fax:321-421-6993
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW91341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGF453ZMedicare UPIN