Healthcare Provider Details

I. General information

NPI: 1760300461
Provider Name (Legal Business Name): ASHLEY LYNN TILLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BRAGDON LN STE 4
KENNEBUNK ME
04043-7262
US

IV. Provider business mailing address

125 BRICKHILL AVE UNIT 212
SOUTH PORTLAND ME
04106-2293
US

V. Phone/Fax

Practice location:
  • Phone: 207-423-0337
  • Fax:
Mailing address:
  • Phone: 207-423-0337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: