Provider Demographics
NPI:1932588902
Name:TILTON, SHAUN RUSSELL (LPCC-S, LICDC)
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:RUSSELL
Last Name:TILTON
Suffix:
Gender:M
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 INDIAN SUMMER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1880
Mailing Address - Country:US
Mailing Address - Phone:937-478-1450
Mailing Address - Fax:
Practice Address - Street 1:592 INDIAN SUMMER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1880
Practice Address - Country:US
Practice Address - Phone:937-478-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-24
Last Update Date:2015-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC.101124101YA0400X
OHE.0800179-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)