Provider Demographics
NPI:1770815441
Name:RICKETSON, TILLMAN R (BCABA)
Entity Type:Individual
Prefix:MR
First Name:TILLMAN
Middle Name:R
Last Name:RICKETSON
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2251
Mailing Address - Country:US
Mailing Address - Phone:850-980-6863
Mailing Address - Fax:
Practice Address - Street 1:1406 HAYS ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2833
Practice Address - Country:US
Practice Address - Phone:850-521-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-07-2340103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst