Provider Demographics
NPI:1659884054
Name:HILLIARD, TINA MARIE (CM)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:HILLIARD
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E WASHINGTON ST STE 150
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3336
Mailing Address - Country:US
Mailing Address - Phone:330-722-1069
Mailing Address - Fax:330-764-9712
Practice Address - Street 1:801 E WASHINGTON ST STE 150
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3336
Practice Address - Country:US
Practice Address - Phone:330-722-1069
Practice Address - Fax:330-764-9712
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1629473160Medicaid