MEDICARE: DARNESIA ALYSE TILLIS LMHCA

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	101YM0800X	Mental Health Counselor	88001579A	IN

General Provider Information

NPI Number	:	1962285064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARNESIA ALYSE TILLIS LMHCA

Provider Business Mailing Address
First Line	:	5412 RUM CHERRY WAY
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-3858
Country	:	US
Telephone Number	:	317-514-9460
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 RUM CHERRY WAY
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-3858
Country	:	US
Telephone Number	:	317-514-9460
Fax Number	:

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

Provider Enumeration Date	:	08/14/2023
Last Update Date	:	08/14/2023

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