=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538750500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAYNE S. AND MAUREEN P TILLMAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2021
-----------------------------------------------------
Last Update Date | 02/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 BAKER ST
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-715-6891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 BAKER ST
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-715-6891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MS. MAUREEN P TILLMAN
-----------------------------------------------------
Credential | L.C.S.W.
-----------------------------------------------------
Telephone | 973-715-6891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------