Provider Demographics
NPI:1760585137
Name:TILLICH, RENE STEPHAN (PHD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:STEPHAN
Last Name:TILLICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 KAWAIHAE ST APT 119
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-5202
Mailing Address - Country:US
Mailing Address - Phone:808-394-2800
Mailing Address - Fax:562-245-6419
Practice Address - Street 1:446 KAWAIHAE ST APT 119
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-5202
Practice Address - Country:US
Practice Address - Phone:808-394-2800
Practice Address - Fax:562-245-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY55103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56622OtherHMSA
HIPSY55OtherQUEENS HEALTH CARE PLAN
HIPSY55OtherQUEENS HEALTH CARE PLAN
S30074Medicare UPIN