Provider Demographics
NPI:1023281557
Name:TIMCHACK, STEPHEN M (PSYD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:TIMCHACK
Suffix:
Gender:M
Credentials:PSYD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 PIERCE ST
Mailing Address - Street 2:SUITE 119
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5512
Mailing Address - Country:US
Mailing Address - Phone:570-714-1981
Mailing Address - Fax:570-714-1983
Practice Address - Street 1:480 PIERCE ST
Practice Address - Street 2:SUITE 119
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5512
Practice Address - Country:US
Practice Address - Phone:570-714-1981
Practice Address - Fax:570-714-1983
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002136101YP2500X
PAPS016722103TC0700X, 103TB0200X, 103TC2200X
PA1-01-0675103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent