Provider Demographics
NPI:1922814649
Name:TILLMAN, LYRIC
Entity type:Individual
Prefix:
First Name:LYRIC
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GERANIUM ST
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3242
Mailing Address - Country:US
Mailing Address - Phone:706-414-5760
Mailing Address - Fax:
Practice Address - Street 1:462 GERANIUM ST
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-3242
Practice Address - Country:US
Practice Address - Phone:706-414-5760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15437104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker