Provider Demographics
NPI:1013146810
Name:TILLMAN, DAMALI MAIA (BA)
Entity Type:Individual
Prefix:
First Name:DAMALI
Middle Name:MAIA
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 CANFIELD CT APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-1742
Mailing Address - Country:US
Mailing Address - Phone:408-300-0950
Mailing Address - Fax:
Practice Address - Street 1:232 E GISH RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4706
Practice Address - Country:US
Practice Address - Phone:408-849-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor