Healthcare Provider Details

I. General information

NPI: 1306660618
Provider Name (Legal Business Name): EMILY TILLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W 2ND STREET
LONOKE AR
72086
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 501-676-3151
  • Fax: 501-676-3152
Mailing address:
  • Phone: 479-750-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2411001
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: