Provider Demographics
NPI:1912020090
Name:TILLMAN, JOSEPH M
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 INDUSTRY WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4000
Mailing Address - Country:US
Mailing Address - Phone:310-639-5983
Mailing Address - Fax:310-639-5870
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:SUITE B
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4000
Practice Address - Country:US
Practice Address - Phone:310-639-5983
Practice Address - Fax:310-639-5870
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical