Provider Demographics
NPI:1538496252
Name:TIMBERLAKE, MELVIN DEAN (LICDC)
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:DEAN
Last Name:TIMBERLAKE
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 LABELLE ST
Mailing Address - Street 2:
Mailing Address - City:BRILLIANT
Mailing Address - State:OH
Mailing Address - Zip Code:43913-1120
Mailing Address - Country:US
Mailing Address - Phone:740-381-3557
Mailing Address - Fax:740-598-3956
Practice Address - Street 1:817 LABELLE ST
Practice Address - Street 2:
Practice Address - City:BRILLIANT
Practice Address - State:OH
Practice Address - Zip Code:43913-1120
Practice Address - Country:US
Practice Address - Phone:740-381-3557
Practice Address - Fax:740-598-3956
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH965747101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)