Healthcare Provider Details

I. General information

NPI: 1558003012
Provider Name (Legal Business Name): MARGO LOUISE TILLSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N HIGH ST
COLUMBUS OH
43201-2460
US

IV. Provider business mailing address

1400 NEIL AVE APT 204
COLUMBUS OH
43201-3804
US

V. Phone/Fax

Practice location:
  • Phone: 614-299-6600
  • Fax:
Mailing address:
  • Phone: 440-668-6247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.2202359-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: