Provider Demographics
NPI:1821658360
Name:RENDELL, TIMOTHY MAITLAND
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MAITLAND
Last Name:RENDELL
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 1:101 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3602
Mailing Address - Country:US
Mailing Address - Phone:707-345-4012
Mailing Address - Fax:
Practice Address - Street 1:101 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3602
Practice Address - Country:US
Practice Address - Phone:707-345-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator