Provider Demographics
NPI:1174764054
Name:PREVOST, TIMOTHY SAMUEL (MSW)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SAMUEL
Last Name:PREVOST
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22064 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2114
Mailing Address - Country:US
Mailing Address - Phone:586-808-8957
Mailing Address - Fax:
Practice Address - Street 1:16200 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1103
Practice Address - Country:US
Practice Address - Phone:586-263-8669
Practice Address - Fax:586-263-8669
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080110104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker