Provider Demographics
NPI:1699913640
Name:TILLAR-COACHMAN, DEMETRA ME'QUAN (LCSW)
Entity type:Individual
Prefix:
First Name:DEMETRA
Middle Name:ME'QUAN
Last Name:TILLAR-COACHMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 PIER VIEW WAY STE A
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-2848
Mailing Address - Country:US
Mailing Address - Phone:773-971-2457
Mailing Address - Fax:
Practice Address - Street 1:705 PIER VIEW WAY STE A
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2848
Practice Address - Country:US
Practice Address - Phone:442-500-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0139641041C0700X
GACSW0056661041C0700X
CALCSW884391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical