Healthcare Provider Details

I. General information

NPI: 1104167899
Provider Name (Legal Business Name): MELANIE HICKS TILLMAN M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 FRANCES MEEKS WAY SUITE 9
RICHMOND HILL GA
31324-3983
US

IV. Provider business mailing address

2551 FORT MCALLISTER RD
RICHMOND HILL GA
31324-4847
US

V. Phone/Fax

Practice location:
  • Phone: 912-727-2321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberGA#SLP006977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: