Provider Demographics
NPI:1639299050
Name:TILLMAN, LEE R (RAS)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:R
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3729
Mailing Address - Country:US
Mailing Address - Phone:707-579-0775
Mailing Address - Fax:707-576-7845
Practice Address - Street 1:1901 CLEVELAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4282
Practice Address - Country:US
Practice Address - Phone:707-576-0818
Practice Address - Fax:707-576-7845
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARAST0412211559101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)