Provider Demographics
NPI:1528380623
Name:TILLERY, RICARDO DAVID (MBA, LMSW, ICAADC)
Entity type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:DAVID
Last Name:TILLERY
Suffix:
Gender:M
Credentials:MBA, LMSW, ICAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 W MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3600
Mailing Address - Country:US
Mailing Address - Phone:517-515-6176
Mailing Address - Fax:
Practice Address - Street 1:3721 W MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3600
Practice Address - Country:US
Practice Address - Phone:517-515-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02622101YA0400X
103K00000X, 104100000X, 104100000X, 1041C0700X
MI68010948351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396128088Medicaid