Provider Demographics
NPI:1396946877
Name:TILSON, BEVERLY DIANE (LAADC-CA LCI2361214)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:DIANE
Last Name:TILSON
Suffix:
Gender:F
Credentials:LAADC-CA LCI2361214
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GOUGH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5903
Mailing Address - Country:US
Mailing Address - Phone:415-553-3252
Mailing Address - Fax:
Practice Address - Street 1:101 GOUGH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102
Practice Address - Country:US
Practice Address - Phone:415-553-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI2361214101YA0400X
CARWQ111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-068218OtherCAARR