Provider Demographics
NPI:1225271000
Name:TILLEY, DONNA L (MHRT-1)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:TILLEY
Suffix:
Gender:F
Credentials:MHRT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WESLEYAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04742-2010
Mailing Address - Country:US
Mailing Address - Phone:207-473-9285
Mailing Address - Fax:207-473-9403
Practice Address - Street 1:8 WESLEYAN ST
Practice Address - Street 2:
Practice Address - City:FORT FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04742-2010
Practice Address - Country:US
Practice Address - Phone:207-473-9285
Practice Address - Fax:207-473-9403
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000Medicaid