Provider Demographics
NPI:1447954102
Name:TILLMAN, SHAQUITA (LGPC)
Entity type:Individual
Prefix:
First Name:SHAQUITA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 BOOKER DR
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-1830
Mailing Address - Country:US
Mailing Address - Phone:301-254-4387
Mailing Address - Fax:
Practice Address - Street 1:2218 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2827
Practice Address - Country:US
Practice Address - Phone:202-717-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC20001368101YS0200X
DCLGPC200001368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool