Provider Demographics
NPI:1528218328
Name:TILL, MICHAEL GEORGE (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:TILL
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17844 E 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1840
Mailing Address - Country:US
Mailing Address - Phone:816-254-3652
Mailing Address - Fax:816-254-9243
Practice Address - Street 1:17844 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1840
Practice Address - Country:US
Practice Address - Phone:816-254-3652
Practice Address - Fax:816-254-9243
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008004864103TC0700X
MO20070336581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical