MEDICARE: TILLARY TICE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	TPSW753	TX
2	1041C0700X	Clinical Social Worker	TPSW753	NH
3	1041C0700X	Clinical Social Worker	CSW.09928294	CO
4	1041C0700X	Clinical Social Worker	118829	IA
5	1041C0700X	Clinical Social Worker	C013683	NC

General Provider Information

NPI Number	:	1326607417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TILLARY TICE LCSW

Provider Business Mailing Address
First Line	:	67 ROBERT BAKER CT
Second Line	:
City	:	HINESVILLE
State	:	GA
Zip	:	31313-0032
Country	:	US
Telephone Number	:	609-949-1661
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 WOODMONT LN NW
Second Line	:	SUITE 389
City	:	ATLANTA
State	:	GA
Zip	:	30318
Country	:	US
Telephone Number	:	609-949-1661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	03/04/2026

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Directions to “ TILLARY TICE LCSW” Practice Location

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