Healthcare Provider Details

I. General information

NPI: 1770815441
Provider Name (Legal Business Name): TILLMAN R RICKETSON BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5033 SULLIVANT AVE
COLUMBUS OH
43228-1749
US

IV. Provider business mailing address

2987 BAYSHORE DR
TALLAHASSEE FL
32309-2251
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 850-980-6863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-07-2340
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-07-2340
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: