Provider Demographics
NPI:1558003012
Name:TILLSTROM, MARGO LOUISE
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:LOUISE
Last Name:TILLSTROM
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 1:1400 NEIL AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3804
Mailing Address - Country:US
Mailing Address - Phone:440-668-6247
Mailing Address - Fax:
Practice Address - Street 1:1301 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2460
Practice Address - Country:US
Practice Address - Phone:614-299-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.2202359-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator