Provider Demographics
NPI:1023688728
Name:TYLLAS, MICHAEL ALAN (LCSW, PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:TYLLAS
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SHERIDAN RD UNIT 5L
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1892
Mailing Address - Country:US
Mailing Address - Phone:773-550-6022
Mailing Address - Fax:
Practice Address - Street 1:1500 SHERIDAN RD UNIT 5L
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1892
Practice Address - Country:US
Practice Address - Phone:773-550-6022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490055141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149005514OtherIDFPR LICENSE