Provider Demographics
NPI:1114159696
Name:TILLIS, DAVID ROGER (LPC, NCC, MAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROGER
Last Name:TILLIS
Suffix:
Gender:M
Credentials:LPC, NCC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9635 VENTANA WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8620
Mailing Address - Country:US
Mailing Address - Phone:770-495-6339
Mailing Address - Fax:770-495-6338
Practice Address - Street 1:9635 VENTANA WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8620
Practice Address - Country:US
Practice Address - Phone:770-495-6339
Practice Address - Fax:770-495-6338
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMAC030853101YA0400X
GALPC001626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)