Provider Demographics
NPI:1154748275
Name:TILLMAN SMALL, SONYA
Entity type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:
Last Name:TILLMAN SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10105 SE 165TH LN
Mailing Address - Street 2:
Mailing Address - City:WHITE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32096-2119
Mailing Address - Country:US
Mailing Address - Phone:386-234-0222
Mailing Address - Fax:
Practice Address - Street 1:10105 SE 165TH LN
Practice Address - Street 2:
Practice Address - City:WHITE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32096-2119
Practice Address - Country:US
Practice Address - Phone:386-234-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator