Provider Demographics
NPI:1760702740
Name:TIMMCKE, RONALD LEE (MA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:LEE
Last Name:TIMMCKE
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 1:13204 SILVER PEAK PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8261
Mailing Address - Country:US
Mailing Address - Phone:505-850-7301
Mailing Address - Fax:
Practice Address - Street 1:4253 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 220
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1106
Practice Address - Country:US
Practice Address - Phone:505-342-0400
Practice Address - Fax:505-342-0500
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3907101YA0400X
NM2741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ4928Medicaid
NM000189347OtherOPTUM HEALTH NEW MEXICO
NM1054648OtherCIGNA BEHAVIORAL HEALTH INC.
NM43728OtherPRESBYTERIAN