Provider Demographics
NPI:1538557624
Name:TILLMAN, AMOND
Entity type:Individual
Prefix:
First Name:AMOND
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 MILL HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2865
Mailing Address - Country:US
Mailing Address - Phone:203-953-3369
Mailing Address - Fax:
Practice Address - Street 1:399 MILL HILL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2865
Practice Address - Country:US
Practice Address - Phone:203-953-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001099101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)