Provider Demographics
NPI:1861790446
Name:MCNICHOL, TIMOTHY M
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:MCNICHOL
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 1:6851 S EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4118
Mailing Address - Country:US
Mailing Address - Phone:503-888-5804
Mailing Address - Fax:
Practice Address - Street 1:1212 SW CLAY ST APT 711
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-7827
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:503-238-5202
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IL1490201011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator