Provider Demographics
NPI:1144543760
Name:TILLMAN, PAMELA LYNN (PMHP)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:LYNN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5858
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5858
Mailing Address - Country:US
Mailing Address - Phone:308-381-7487
Mailing Address - Fax:308-381-2712
Practice Address - Street 1:3532 W CAPITAL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-1205
Practice Address - Country:US
Practice Address - Phone:308-381-7487
Practice Address - Fax:308-381-2712
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077707526Medicaid
NE098184OtherMEDICARE