Basic Information
| Provider Information | |||||||||
| NPI: | 1649505306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | SUITE 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | 7148344595 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | SUITE 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | 7148344595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2009 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 46391 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.