Provider Demographics
NPI:1689902785
Name:TILLEY, MATTIE (LMSW)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:TILLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 WINDING WOLF PL APT 301
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2907
Mailing Address - Country:US
Mailing Address - Phone:901-369-1400
Mailing Address - Fax:
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1420
Practice Address - Fax:901-369-1433
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8147104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker