Provider Demographics
NPI:1669481883
Name:TILLMAN, LISA BAKER (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:BAKER
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 KENILWORTH DR
Practice Address - Street 2:SUITE 301
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2139
Practice Address - Country:US
Practice Address - Phone:410-952-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD048761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQT99OtherBCBS