Provider Demographics
NPI:1356866750
Name:BLACKMAN, TILLARY BLAINE (PSYD)
Entity Type:Individual
Prefix:
First Name:TILLARY
Middle Name:BLAINE
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 N SEELEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6221
Mailing Address - Country:US
Mailing Address - Phone:872-302-7123
Mailing Address - Fax:
Practice Address - Street 1:1700 W IRVING PARK RD STE 305B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2462
Practice Address - Country:US
Practice Address - Phone:312-585-6965
Practice Address - Fax:877-655-9891
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical