Provider Demographics
NPI:1740793819
Name:TILLMAN, STAUTCIA (MS, LPC, NCC)
Entity type:Individual
Prefix:
First Name:STAUTCIA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81384
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9384
Mailing Address - Country:US
Mailing Address - Phone:404-472-6224
Mailing Address - Fax:
Practice Address - Street 1:920 GREEN ST SW STE B
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5310
Practice Address - Country:US
Practice Address - Phone:678-304-8902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010415101YM0800X
GAAPC004552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health