Provider Demographics
NPI:1497502785
Name:KILGORE, TIMOTHY JR
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:KILGORE
Suffix:JR
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 1:6621 KINGS POINTE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8798
Mailing Address - Country:US
Mailing Address - Phone:810-874-5879
Mailing Address - Fax:
Practice Address - Street 1:126 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8623
Practice Address - Country:US
Practice Address - Phone:810-458-4718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022908101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor