Provider Demographics
NPI:1851404206
Name:ENEVOLDSEN, TIMOTHY JOHN (MED, LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:ENEVOLDSEN
Suffix:
Gender:M
Credentials:MED, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50291
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0291
Mailing Address - Country:US
Mailing Address - Phone:806-570-3775
Mailing Address - Fax:806-356-8189
Practice Address - Street 1:6666 W AMARILLO BLVD
Practice Address - Street 2:SUITE 28
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1756
Practice Address - Country:US
Practice Address - Phone:806-570-3775
Practice Address - Fax:806-356-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10727101YP2500X
TX003822-042155106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095362201Medicaid