Basic Information
| Provider Information | |||||||||
| NPI: | 1861790446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNICHOL | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6851 S EVANS AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606374118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038885804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1212 SW CLAY ST APT 711 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972017827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032385203 | ||||||||
| FaxNumber: | 5032385202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2011 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 149020101 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.