Provider Demographics
NPI:1881907129
Name:LUIS, TIMOTHY MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:LUIS
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 1:35 WEST OLENTANGY STREET
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065
Mailing Address - Country:US
Mailing Address - Phone:614-436-4457
Mailing Address - Fax:614-407-9648
Practice Address - Street 1:35 W OLENTANGY ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8717
Practice Address - Country:US
Practice Address - Phone:614-436-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6721101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health