Provider Demographics
NPI:1245249267
Name:TILLICH, JOAN COLUMBIA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:COLUMBIA
Last Name:TILLICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 N NIMITZ HWY
Mailing Address - Street 2:SUITE A203
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4579
Mailing Address - Country:US
Mailing Address - Phone:808-537-9998
Mailing Address - Fax:808-738-5821
Practice Address - Street 1:1130 N NIMITZ HWY
Practice Address - Street 2:SUITE A203
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4579
Practice Address - Country:US
Practice Address - Phone:808-537-9998
Practice Address - Fax:808-738-5821
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW31131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI052502Medicaid
R60088OtherHMSC BCBS
52600Medicare ID - Type Unspecified