Provider Demographics
NPI:1134377211
Name:TILLACK, M'LISA (LCSW)
Entity type:Individual
Prefix:
First Name:M'LISA
Middle Name:
Last Name:TILLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:M'LISA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1780 W 500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3505
Mailing Address - Country:US
Mailing Address - Phone:801-725-4140
Mailing Address - Fax:
Practice Address - Street 1:131 S 700 E STE 102
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-701-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health