Provider Demographics
NPI:1659944403
Name:TILLSON, KATHERINE EMILY (LAC, LCSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:EMILY
Last Name:TILLSON
Suffix:
Gender:F
Credentials:LAC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1702
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-1702
Mailing Address - Country:US
Mailing Address - Phone:415-577-1740
Mailing Address - Fax:
Practice Address - Street 1:208 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:MT
Practice Address - Zip Code:59741-2241
Practice Address - Country:US
Practice Address - Phone:415-577-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)