Provider Demographics
NPI:1720766009
Name:TIMMERMAN, ADDYSON RIAN
Entity Type:Individual
Prefix:
First Name:ADDYSON
Middle Name:RIAN
Last Name:TIMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 W STAMPEDE LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68528-2220
Mailing Address - Country:US
Mailing Address - Phone:402-239-8690
Mailing Address - Fax:
Practice Address - Street 1:1209 HARNEY ST STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1838
Practice Address - Country:US
Practice Address - Phone:402-252-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health