Provider Demographics
NPI:1699063560
Name:TILLMAN, MELVIN THOMAS (PHD, MA)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:THOMAS
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:PHD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5375
Mailing Address - Country:US
Mailing Address - Phone:708-937-5412
Mailing Address - Fax:
Practice Address - Street 1:731 E 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-3448
Practice Address - Country:US
Practice Address - Phone:708-937-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180016155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional