Provider Demographics
NPI:1144784984
Name:TILLIS, DELMAR DANA
Entity Type:Individual
Prefix:
First Name:DELMAR
Middle Name:DANA
Last Name:TILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 RAWSON ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-5523
Mailing Address - Country:US
Mailing Address - Phone:832-732-7626
Mailing Address - Fax:
Practice Address - Street 1:603 D ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3719
Practice Address - Country:US
Practice Address - Phone:415-454-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)