Provider Demographics
NPI:1962285064
Name:TILLIS, DARNESIA ALYSE (LMHCA)
Entity type:Individual
Prefix:
First Name:DARNESIA
Middle Name:ALYSE
Last Name:TILLIS
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 RUM CHERRY WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3858
Mailing Address - Country:US
Mailing Address - Phone:317-514-9460
Mailing Address - Fax:
Practice Address - Street 1:5412 RUM CHERRY WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3858
Practice Address - Country:US
Practice Address - Phone:317-514-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001579A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health