Provider Demographics
NPI:1538757356
Name:DEYOUNG, TIMOTHY LEE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEE
Last Name:DEYOUNG
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 GRIMES AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2838
Mailing Address - Country:US
Mailing Address - Phone:218-252-2448
Mailing Address - Fax:
Practice Address - Street 1:2600 FERNBROOK LN N STE 138
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4752
Practice Address - Country:US
Practice Address - Phone:952-544-0349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist