Provider Demographics
NPI:1184174609
Name:TIM ENEVOLDSEN M.ED., LPC-S, PLLC
Entity type:Organization
Organization Name:TIM ENEVOLDSEN M.ED., LPC-S, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ENEVOLDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MED,LPCS,LMFT,LCDC
Authorized Official - Phone:806-570-3775
Mailing Address - Street 1:6666 W AMARILLO BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1756
Mailing Address - Country:US
Mailing Address - Phone:806-570-3775
Mailing Address - Fax:806-358-3627
Practice Address - Street 1:6666 W AMARILLO BLVD
Practice Address - Street 2:SUITE 4
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:806-358-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095362205Medicaid