Provider Demographics
NPI:1225579840
Name:TILLMAN, KATHLEEN SUZANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUZANNE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S COLUMBIA ROAD, SUITE 202
Mailing Address - Street 2:FAMILY INSTITUTE, PC
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-282-9510
Mailing Address - Fax:
Practice Address - Street 1:2100 S COLUMBIA ROAD, SUITE 202
Practice Address - Street 2:FAMILY INSTITUTE, PC
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-282-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent