Provider Demographics
NPI:1689371254
Name:TAMILLO, MALLORY R (LSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:R
Last Name:TAMILLO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 REVERE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1590
Mailing Address - Country:US
Mailing Address - Phone:224-306-1879
Mailing Address - Fax:224-306-1878
Practice Address - Street 1:60 REVERE DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1590
Practice Address - Country:US
Practice Address - Phone:224-306-1879
Practice Address - Fax:224-306-1878
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105167104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker