Provider Demographics
NPI:1912118803
Name:JAMES, TIMOTHY (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:JAMES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:JAMES
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 LAKESHORE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-8910
Mailing Address - Country:US
Mailing Address - Phone:920-785-3145
Mailing Address - Fax:
Practice Address - Street 1:7517 W. COLDSPRING RD.
Practice Address - Street 2:GREENFIELD REHABILITATION AGENCY INC.
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220
Practice Address - Country:US
Practice Address - Phone:920-559-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3615-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40167100Medicaid