Provider Demographics
NPI:1477018018
Name:TILLMAN, DESONTA
Entity Type:Individual
Prefix:
First Name:DESONTA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4708
Mailing Address - Country:US
Mailing Address - Phone:773-793-4155
Mailing Address - Fax:
Practice Address - Street 1:2930 S MICHIGAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3484
Practice Address - Country:US
Practice Address - Phone:773-819-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101YM0800XMedicaid