Provider Demographics
NPI:1588205272
Name:TILLIMAN, DAMIEN
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:TILLIMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4332 22ND ST STE 203
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5077
Mailing Address - Country:US
Mailing Address - Phone:585-750-0091
Mailing Address - Fax:
Practice Address - Street 1:4332 22ND ST STE 203
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5077
Practice Address - Country:US
Practice Address - Phone:585-750-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022266103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical