Provider Demographics
NPI:1790095784
Name:TILLMAN, MELISSA ANN (PHD)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:STRILCIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1859 LEONARD LN
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4933
Mailing Address - Country:US
Mailing Address - Phone:516-721-7694
Mailing Address - Fax:
Practice Address - Street 1:2174 HEWLETT AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3606
Practice Address - Country:US
Practice Address - Phone:516-858-2877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20158103TC0700X
NY020158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00745088OtherAGENCY'S MEDICAID MMIS #
NY1003991019OtherAGENCY'S NPI #