Provider Demographics
NPI:1902563943
Name:MASSENGILL, TIMOTHY K
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:K
Last Name:MASSENGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:NEOGA
Mailing Address - State:IL
Mailing Address - Zip Code:62447-1404
Mailing Address - Country:US
Mailing Address - Phone:217-419-2260
Mailing Address - Fax:
Practice Address - Street 1:505 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075-1442
Practice Address - Country:US
Practice Address - Phone:217-563-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
160002132225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant