Provider Demographics
NPI:1881075281
Name:TIMBERLAKE, JOHN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:TIMBERLAKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 KATELLA AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3495
Mailing Address - Country:US
Mailing Address - Phone:562-433-7652
Mailing Address - Fax:
Practice Address - Street 1:4132 KATELLA AVE
Practice Address - Street 2:STE 106
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3495
Practice Address - Country:US
Practice Address - Phone:562-743-5232
Practice Address - Fax:562-800-0747
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2017-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27332OtherBOARD OF PSYCHOLOGY