Provider Demographics
NPI:1508072869
Name:TILLMAN, DOUGLAS ROGER (MS ED, PLMHP)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ROGER
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:MS ED, PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 W 39TH ST APT F8
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2778
Mailing Address - Country:US
Mailing Address - Phone:308-352-8568
Mailing Address - Fax:
Practice Address - Street 1:615 N ELM ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-4254
Practice Address - Country:US
Practice Address - Phone:308-395-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8297101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor