Provider Demographics
NPI:1467898221
Name:TILLMAN, MILDRED BENNETT (LCMHC-S,LPC)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:BENNETT
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCMHC-S,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 CALIPER PL
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8380
Mailing Address - Country:US
Mailing Address - Phone:704-388-2710
Mailing Address - Fax:
Practice Address - Street 1:2012 HIGHWAY 160 W
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8401
Practice Address - Country:US
Practice Address - Phone:704-388-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6864101YM0800X
NC10076101YM0800X
NCLCAS-23241101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)