Basic Information
| Provider Information | |||||||||
| NPI: | 1770815441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKETSON | ||||||||
| FirstName: | TILLMAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2987 BAYSHORE DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323092251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509806863 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1406 HAYS ST | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323012833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505210242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2010 | ||||||||
| LastUpdateDate: | 02/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-07-2340 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.