Provider Demographics
NPI:1982145371
Name:TILLMAN, SHANNA (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 KILDAIRE FARM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4587
Mailing Address - Country:US
Mailing Address - Phone:719-725-9575
Mailing Address - Fax:
Practice Address - Street 1:1135 KILDAIRE FARM RD STE 200
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4587
Practice Address - Country:US
Practice Address - Phone:719-725-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSYC.00013493103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical