Provider Demographics
NPI:1477390268
Name:PARKS, TIMOTHY (PHD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PARKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BOTANY BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-3003
Mailing Address - Country:US
Mailing Address - Phone:716-946-3138
Mailing Address - Fax:
Practice Address - Street 1:109 BOTANY BAY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-3003
Practice Address - Country:US
Practice Address - Phone:716-946-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025551-01103TH0100X
SC1890103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service