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General NPI Number Information
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NPI Number | 1730486663
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Entity Type | Organization
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Legal Business Name | WILLOWDEAN D. TILLER, INC.
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Dates
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Enumeration Date | 02/11/2011
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Last Update Date | 02/11/2011
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Provider Practice Location Address
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Address Line | 801 JENKS AVE SUITE C
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City | PANAMA CITY
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State | FL
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Zip | 32401-2576
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Country | US
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Telephone | 850-640-1020
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Fax |
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Provider Business Mailing Address
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Address Line | 128 CHRISTIE LN
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City | PANAMA CITY
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State | FL
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Zip | 32404-7650
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/COUNSELOR
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Name | MRS. WILLOWDEAN D TILLER
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Credential | LMHC
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Telephone | 850-640-1020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | MH 6007
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License Number State | FL
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