Provider Demographics
NPI:1609004456
Name:STILLWELL, TINA (LSCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:STILLWELL
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:619 COURT ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-2607
Mailing Address - Country:US
Mailing Address - Phone:785-630-5500
Mailing Address - Fax:785-630-5295
Practice Address - Street 1:619 COURT ST
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-2607
Practice Address - Country:US
Practice Address - Phone:785-630-5500
Practice Address - Fax:785-630-5295
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS80-057-20591041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200656790AMedicaid
KS200656790AOtherMEDICAID
KSKA1795Medicaid