Basic Information
| Provider Information | |||||||||
| NPI: | 1912020090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 INDUSTRY WAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106395983 | ||||||||
| FaxNumber: | 3106395870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 INDUSTRY WAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106395983 | ||||||||
| FaxNumber: | 3106395870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7697 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.