Provider Demographics
NPI:1245786623
Name:KING, CONSTANCE TILLMAN
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:TILLMAN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:DEBORAH
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1802 LEMAR AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3331
Mailing Address - Country:US
Mailing Address - Phone:847-293-5683
Mailing Address - Fax:
Practice Address - Street 1:10046 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1926
Practice Address - Country:US
Practice Address - Phone:773-429-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health