Provider Demographics
NPI:1144530742
Name:FERMAN-TILLIS, LARAE J (PHD,LSW)
Entity type:Individual
Prefix:
First Name:LARAE
Middle Name:J
Last Name:FERMAN-TILLIS
Suffix:
Gender:F
Credentials:PHD,LSW
Other - Prefix:
Other - First Name:LARAE
Other - Middle Name:J
Other - Last Name:TILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LSW
Mailing Address - Street 1:15408 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3704
Mailing Address - Country:US
Mailing Address - Phone:216-287-8925
Mailing Address - Fax:
Practice Address - Street 1:1293 COPLEY RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2766
Practice Address - Country:US
Practice Address - Phone:216-773-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00294271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid