Provider Demographics
NPI:1285014753
Name:TILLMAN, LAURA MICHELLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3151
Mailing Address - Country:US
Mailing Address - Phone:803-422-7451
Mailing Address - Fax:
Practice Address - Street 1:2012 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3151
Practice Address - Country:US
Practice Address - Phone:803-422-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2015-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1803235Z00000X
GASLP008791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist