Provider Demographics
NPI:1649428061
Name:TILLMAN, GINA MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:BRANCATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1808 ORCHID ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5131
Mailing Address - Country:US
Mailing Address - Phone:941-313-7040
Mailing Address - Fax:
Practice Address - Street 1:1808 ORCHID ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5131
Practice Address - Country:US
Practice Address - Phone:941-313-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00076724101YA0400X
FLSW127581041C0700X
NY0804831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)