Provider Demographics
NPI:1477228351
Name:TILLMAN, SHAWNYETTA DANYEL (MSW,LCSW-A)
Entity Type:Individual
Prefix:
First Name:SHAWNYETTA
Middle Name:DANYEL
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MSW,LCSW-A
Other - Prefix:MRS
Other - First Name:SHAWNYETTA
Other - Middle Name:DANYEL
Other - Last Name:TILLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2812 ROSEMEADE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9102
Mailing Address - Country:US
Mailing Address - Phone:910-286-1670
Mailing Address - Fax:
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-286-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP016608101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor