Provider Demographics
NPI:1710369582
Name:TILLMAN, DEVONNA (LAC)
Entity Type:Individual
Prefix:
First Name:DEVONNA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:DEVONNA
Other - Middle Name:
Other - Last Name:FRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:829 HALBERT ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2607
Mailing Address - Country:US
Mailing Address - Phone:501-332-4400
Mailing Address - Fax:501-332-4400
Practice Address - Street 1:1420 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-0000
Practice Address - Country:US
Practice Address - Phone:870-777-4848
Practice Address - Fax:870-777-2410
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA2009117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227972795Medicaid