Provider Demographics
NPI:1114589991
Name:TILLMAN, IVY DENISE (LCSW)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:DENISE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5559 SHERRY CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-3525
Mailing Address - Country:US
Mailing Address - Phone:571-274-0109
Mailing Address - Fax:
Practice Address - Street 1:1727 KING ST STE 105
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2700
Practice Address - Country:US
Practice Address - Phone:703-831-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical