Provider Demographics
NPI:1023490547
Name:TILLMAN-SMITH, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:TILLMAN-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:TILLMAN-SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW MSW
Mailing Address - Street 1:103 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3101
Mailing Address - Country:US
Mailing Address - Phone:508-580-4691
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3101
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3138801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical