Provider Demographics
NPI:1922184316
Name:TAVIS, TIMOTHY M (PH D)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:TAVIS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 E BLUE HERON BLVD # 162
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-4739
Mailing Address - Country:US
Mailing Address - Phone:561-882-4008
Mailing Address - Fax:561-881-4432
Practice Address - Street 1:1900 S OLIVE AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-7726
Practice Address - Country:US
Practice Address - Phone:561-882-4008
Practice Address - Fax:561-881-4432
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54714Medicare ID - Type UnspecifiedMEDICARE PROVIDER #