Provider Demographics
NPI:1902393606
Name:CARSON, TIMIYA SHERARD
Entity Type:Individual
Prefix:MR
First Name:TIMIYA
Middle Name:SHERARD
Last Name:CARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TIMIYA
Other - Middle Name:SHERARD
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2420 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-5808
Mailing Address - Country:US
Mailing Address - Phone:850-968-3565
Mailing Address - Fax:850-968-3565
Practice Address - Street 1:2420 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-5808
Practice Address - Country:US
Practice Address - Phone:850-968-3565
Practice Address - Fax:850-968-3565
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)