Provider Demographics
NPI:1013547215
Name:TILLMAN, LORRAINE (LMSW)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:
Other - Last Name:TILLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1154 SAINT PHILLIPS CT
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4360
Mailing Address - Country:US
Mailing Address - Phone:770-898-4478
Mailing Address - Fax:
Practice Address - Street 1:2012 EASTVIEW PKWY STE 400
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-5701
Practice Address - Country:US
Practice Address - Phone:770-679-0586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW009065104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker