Provider Demographics
NPI:1396622882
Name:TIMM, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:TIMM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15455 CONWAY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-6022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15455 CONWAY RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-6022
Practice Address - Country:US
Practice Address - Phone:636-675-7566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor