Provider Demographics
NPI:1871092536
Name:TILLERSON, RACHAEL (MA)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:TILLERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 N I 35
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-3408
Mailing Address - Country:US
Mailing Address - Phone:940-387-3450
Mailing Address - Fax:
Practice Address - Street 1:4222 N I 35
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-3408
Practice Address - Country:US
Practice Address - Phone:940-387-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75101OtherTEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS