Provider Demographics
NPI:1891961744
Name:TILLMANN, GLORIA YRIZARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:YRIZARRY
Last Name:TILLMANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 RED HAWK RD NO
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722
Mailing Address - Country:US
Mailing Address - Phone:732-946-3648
Mailing Address - Fax:
Practice Address - Street 1:14 RED HAWK RD NO
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722
Practice Address - Country:US
Practice Address - Phone:732-946-3648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ1720103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1720OtherNJ LICENSE
NJ195502Medicare UPIN
1720OtherNJ LICENSE