Provider Demographics
NPI:1033109350
Name:TILLER, WILLOWDEAN (LMHC)
Entity Type:Individual
Prefix:
First Name:WILLOWDEAN
Middle Name:
Last Name:TILLER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 JENKS AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2576
Mailing Address - Country:US
Mailing Address - Phone:850-640-1020
Mailing Address - Fax:850-640-1022
Practice Address - Street 1:801 JENKS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2576
Practice Address - Country:US
Practice Address - Phone:850-640-1020
Practice Address - Fax:850-640-1022
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6007101YM0800X
FL984101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762242200Medicaid