Healthcare Provider Details

I. General information

NPI: 1619894821
Provider Name (Legal Business Name): SANDRA LEE TILLMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 FREMAUX AVE
SLIDELL LA
70458-3319
US

IV. Provider business mailing address

223 DOGWOOD ST
SLIDELL LA
70460-6925
US

V. Phone/Fax

Practice location:
  • Phone: 985-773-8880
  • Fax:
Mailing address:
  • Phone: 985-773-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9802
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: