Provider Demographics
NPI:1205222312
Name:TILLMAN, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:TILLMAN
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 1:9111 CROSS PARK DR
Mailing Address - Street 2:SUITE D200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4506
Mailing Address - Country:US
Mailing Address - Phone:804-335-5997
Mailing Address - Fax:
Practice Address - Street 1:9111 CROSS PARK DR
Practice Address - Street 2:SUITE D200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4506
Practice Address - Country:US
Practice Address - Phone:919-394-4169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health