Provider Demographics
NPI:1508411026
Name:KILLIAN, TRISTAN WAYNE (LCSW, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:WAYNE
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 BEAVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-9081
Mailing Address - Country:US
Mailing Address - Phone:828-201-6901
Mailing Address - Fax:
Practice Address - Street 1:3114 E BURMA RD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-8718
Practice Address - Country:US
Practice Address - Phone:828-201-6901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25220101YA0400X
NCC015255101Y00000X, 101YP2500X, 171M00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator