Healthcare Provider Details

I. General information

NPI: 1215261243
Provider Name (Legal Business Name): STEVEN OWEN TILLMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 MIDDLEVILLE RD
NORTHPORT NY
11768-2200
US

IV. Provider business mailing address

10000 BAY PINES BLVD UNIT 117
BAY PINES FL
33744-8200
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-4400
  • Fax:
Mailing address:
  • Phone: 727-398-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080628
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: