MEDICARE: ANSLEY MADISON TILLMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-22-242788	GA

General Provider Information

NPI Number	:	1861203762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANSLEY MADISON TILLMAN

Provider Business Mailing Address
First Line	:	4104 LANTERN LN
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-6720
Country	:	US
Telephone Number	:	229-251-5589
Fax Number	:

Provider Business Practice Location Address
First Line	:	406 JACKSON CIR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-4928
Country	:	US
Telephone Number	:	229-251-5589
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2025
Last Update Date	:	03/04/2025

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Directions to “ ANSLEY MADISON TILLMAN ” Practice Location

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