Provider Demographics
NPI:1558925883
Name:THILLMAN, LAWRENCE T (MA, MDIV)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:T
Last Name:THILLMAN
Suffix:
Gender:M
Credentials:MA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E SIMPSON ST STE G9
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2350
Mailing Address - Country:US
Mailing Address - Phone:720-282-9948
Mailing Address - Fax:
Practice Address - Street 1:400 E SIMPSON ST STE G9
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2350
Practice Address - Country:US
Practice Address - Phone:720-282-9948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0108744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20181376060OtherARTICLES OF ORGANIZATION