Provider Demographics
NPI:1427134311
Name:TILLMAN, SUSAN ANN (MS ED)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:MS
Other - First Name:SUSYN
Other - Middle Name:A W
Other - Last Name:TILLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS ED
Mailing Address - Street 1:14192 ROOSEVELT HWY
Mailing Address - Street 2:
Mailing Address - City:WATERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14571-9750
Mailing Address - Country:US
Mailing Address - Phone:585-682-9740
Mailing Address - Fax:585-589-7341
Practice Address - Street 1:14369 RIDGE RD WEST
Practice Address - Street 2:SUITE 2
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411
Practice Address - Country:US
Practice Address - Phone:585-682-0338
Practice Address - Fax:585-589-7341
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLMHC 1260101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor