Provider Demographics
NPI:1972298644
Name:TIMBERLAKE, ELISHA
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PARKWAY, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:300 INTERNATIONAL PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3625
Practice Address - Country:US
Practice Address - Phone:866-610-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician