Provider Demographics
NPI:1356320790
Name:TILLEY, GEORGE EDWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:EDWARD
Last Name:TILLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6600
Mailing Address - Country:US
Mailing Address - Phone:910-798-6587
Mailing Address - Fax:910-798-6643
Practice Address - Street 1:2029 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6600
Practice Address - Country:US
Practice Address - Phone:910-798-6587
Practice Address - Fax:910-798-6643
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0030701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13006OtherBLUE CROSS AND BLUE SHIEL
NC132A0OtherBLUE CROSS/BLUE SHIELD
NC6003469Medicaid
NC6002292Medicaid
NC132A0OtherBLUE CROSS/BLUE SHIELD