Provider Demographics
NPI:1407188261
Name:TILLMAN, NICOLE BERNADINE (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BERNADINE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 ARENA DR STE 460A
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-3755
Mailing Address - Country:US
Mailing Address - Phone:301-825-4739
Mailing Address - Fax:
Practice Address - Street 1:9500 ARENA DR STE 460A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-3755
Practice Address - Country:US
Practice Address - Phone:301-825-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD150691041C0700X
DCLC500786041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical