Provider Demographics
NPI:1184769283
Name:JOHN, TIMOTHY T (CCC-SLP,L)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:T
Last Name:JOHN
Suffix:
Gender:M
Credentials:CCC-SLP,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3619
Mailing Address - Country:US
Mailing Address - Phone:815-588-1623
Mailing Address - Fax:
Practice Address - Street 1:1807 EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546
Practice Address - Country:US
Practice Address - Phone:819-934-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist