Provider Demographics
NPI:1386283513
Name:TILLMAN, AMANDA NICHOLE STACEY
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLE STACEY
Last Name:TILLMAN
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 1:2611 INSPIRATION TRAIL PARKWAY
Mailing Address - Street 2:APT 301
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219
Mailing Address - Country:US
Mailing Address - Phone:614-434-6342
Mailing Address - Fax:
Practice Address - Street 1:345 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3623
Practice Address - Country:US
Practice Address - Phone:614-434-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health