Provider Demographics
NPI:1851618391
Name:TILLMAN, KHADIJAH ELLA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:ELLA
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CHELMSFORD RD.
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609
Mailing Address - Country:US
Mailing Address - Phone:585-713-2071
Mailing Address - Fax:
Practice Address - Street 1:4 CHELMSFORD RD.
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609
Practice Address - Country:US
Practice Address - Phone:585-713-2071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72074482104100000X
NY0816031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker