Provider Demographics
NPI:1366931156
Name:DONALD, WILLIE TIMOTHY JR (TECHNICIAN)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:TIMOTHY
Last Name:DONALD
Suffix:JR
Gender:M
Credentials:TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4530
Mailing Address - Country:US
Mailing Address - Phone:219-344-8909
Mailing Address - Fax:
Practice Address - Street 1:4755 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4530
Practice Address - Country:US
Practice Address - Phone:219-344-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician