Provider Demographics
NPI:1720600695
Name:IDENTITY COUNSELING PSYCHOLOGY WEST PLLC
Entity Type:Organization
Organization Name:IDENTITY COUNSELING PSYCHOLOGY WEST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:734-545-0332
Mailing Address - Street 1:635 S MAPLE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3838
Mailing Address - Country:US
Mailing Address - Phone:734-645-8944
Mailing Address - Fax:
Practice Address - Street 1:635 S MAPLE RD STE 2
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3838
Practice Address - Country:US
Practice Address - Phone:734-645-8944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty