=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841664836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TILLMAN THERAPEUTIC SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2015
-----------------------------------------------------
Last Update Date | 11/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1808 ORCHID ST
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-313-7040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5530 GOODPASTURE GLN
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-313-7040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADULT & FAMILY THERAPIST
-----------------------------------------------------
Name | GINA TILLMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 941-313-7040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW12758
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW12757
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------