Provider Demographics
NPI:1831375252
Name:TIMBERLAKE, TERRI LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:TERRI
Middle Name:LYNN
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13435 SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1448
Mailing Address - Country:US
Mailing Address - Phone:718-977-8022
Mailing Address - Fax:718-883-6669
Practice Address - Street 1:13435 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-1448
Practice Address - Country:US
Practice Address - Phone:718-977-8022
Practice Address - Fax:718-883-6669
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02920212Medicaid