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General NPI Number Information
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NPI Number | 1740793819
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Entity Type | Individual
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Provider Name | STAUTCIA TILLMAN MS, LPC, NCC
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Gender | Female
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Dates
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Enumeration Date | 11/13/2017
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Last Update Date | 10/30/2025
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Provider Practice Location Address
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Address Line | 920 GREEN ST SW STE B
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City | CONYERS
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State | GA
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Zip | 30012-5310
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Country | US
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Telephone | 678-304-8902
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 81384
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City | CONYERS
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State | GA
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Zip | 30013-9384
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Country | US
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Telephone | 404-472-6224
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC010415
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | APC004552
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License Number State | GA
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