Provider Demographics
NPI:1245074319
Name:HARLOS, TIMOTHY JAMES (LLC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:HARLOS
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8315
Mailing Address - Country:US
Mailing Address - Phone:330-671-9880
Mailing Address - Fax:
Practice Address - Street 1:1388 BALDWIN ST # A
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8937
Practice Address - Country:US
Practice Address - Phone:330-671-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional