Provider Demographics
NPI:1508118985
Name:TILLMAN, ROY JEAN
Entity Type:Individual
Prefix:MS
First Name:ROY
Middle Name:JEAN
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 1:2056 E 73RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2904
Mailing Address - Country:US
Mailing Address - Phone:773-218-2165
Mailing Address - Fax:
Practice Address - Street 1:2056 E 73RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2904
Practice Address - Country:US
Practice Address - Phone:773-218-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1981536222Q00000X
IL1981534222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist