Provider Demographics
NPI:1770243917
Name:ZIMMER, TY W
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:W
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SEA AVE SPC 23
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-5968
Mailing Address - Country:US
Mailing Address - Phone:707-502-0075
Mailing Address - Fax:
Practice Address - Street 1:2413 2ND ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0811
Practice Address - Country:US
Practice Address - Phone:707-269-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)