Provider Demographics
NPI:1417549007
Name:TILLMAN, EDWIN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 19TH ST APT 59
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-4268
Mailing Address - Country:US
Mailing Address - Phone:310-388-7365
Mailing Address - Fax:
Practice Address - Street 1:9920 19TH ST APT 59
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737-4268
Practice Address - Country:US
Practice Address - Phone:310-388-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician