Provider Demographics
NPI:1427112457
Name:TILLMAN, WAYNE S (PHD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:S
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-5218
Mailing Address - Country:US
Mailing Address - Phone:973-267-5586
Mailing Address - Fax:973-540-0084
Practice Address - Street 1:48 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-5218
Practice Address - Country:US
Practice Address - Phone:973-267-5586
Practice Address - Fax:973-540-0084
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00158900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ618119Medicare PIN