Provider Demographics
NPI:1992224182
Name:TILLERY, CYNTHIA PETERS (LPC, CSC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:PETERS
Last Name:TILLERY
Suffix:
Gender:F
Credentials:LPC, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4354 FM 2112
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-8785
Mailing Address - Country:US
Mailing Address - Phone:936-205-0283
Mailing Address - Fax:
Practice Address - Street 1:3524 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-8728
Practice Address - Country:US
Practice Address - Phone:936-560-6855
Practice Address - Fax:936-560-6855
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64398101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty