Provider Demographics
NPI:1790317956
Name:JERVIS, TIMOTHY E (CASAC-T CRPA-P)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:JERVIS
Suffix:
Gender:M
Credentials:CASAC-T CRPA-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 AMSTERDAM PL APT 4A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1474
Mailing Address - Country:US
Mailing Address - Phone:646-271-3281
Mailing Address - Fax:
Practice Address - Street 1:20 SICKLES AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4030
Practice Address - Country:US
Practice Address - Phone:914-613-0700
Practice Address - Fax:914-355-5425
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)