Provider Demographics
NPI:1053935981
Name:SOLOMON, TIMOTHY D (IMH 16596)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:D
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:IMH 16596
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13417 LITTLE GEM CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7924
Mailing Address - Country:US
Mailing Address - Phone:239-462-2204
Mailing Address - Fax:
Practice Address - Street 1:12557 NEW BRITTANY BLVD STE 31-2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3651
Practice Address - Country:US
Practice Address - Phone:239-939-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health