Provider Demographics
NPI:1013633189
Name:TILLMAN, MACY A
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:A
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:A
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW LSCSW
Mailing Address - Street 1:7211 E 131ST ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3318
Mailing Address - Country:US
Mailing Address - Phone:816-204-6654
Mailing Address - Fax:
Practice Address - Street 1:7211 E 131ST ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-3318
Practice Address - Country:US
Practice Address - Phone:816-204-6654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220148011041C0700X
KSLSCSW058291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical