Provider Demographics
NPI:1871784330
Name:SALLY A TIMMONS LLC
Entity type:Organization
Organization Name:SALLY A TIMMONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW RN
Authorized Official - Phone:765-404-6431
Mailing Address - Street 1:1805 SKYLINE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905
Mailing Address - Country:US
Mailing Address - Phone:765-404-6431
Mailing Address - Fax:765-477-7843
Practice Address - Street 1:120 SAGAMORE PARKWAY WEST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906
Practice Address - Country:US
Practice Address - Phone:765-404-6431
Practice Address - Fax:765-477-7843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALLY A TIMMONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-08
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004910A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000375779OtherANTHEM BCBS
IN233410Medicare PIN