Provider Demographics
NPI:1831980267
Name:FANCOTE, TIM ROY JR (LSW)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:ROY
Last Name:FANCOTE
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3806
Mailing Address - Country:US
Mailing Address - Phone:513-228-6590
Mailing Address - Fax:
Practice Address - Street 1:134 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3806
Practice Address - Country:US
Practice Address - Phone:513-228-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2411693104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker