Active NPI
David Roger Tillis, LPC, NCC, MAC
- Professional Counselor
- Johns Creek, GA
National Provider Identifier
1114159696
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- LPC001626
- Practice address
- 9635 Ventana Way
Suite 101
Johns Creek, GA 30022-8620 - Phone
- (770) 495-6339
- Fax
- (770) 495-6338
- NPI assigned
- Aug 17, 2009
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | MAC030853 | GA | |
| Professional Counselor | 101YP2500X | LPC001626 | GA | Primary |
Addresses
Primary practice location
9635 Ventana Way
Suite 101
Johns Creek, GA 30022-8620
Mailing address
9635 Ventana Way
Suite 101
Johns Creek, GA 30022-8620
Phone (770) 495-6339
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MAC030853 | GA | MD | Addiction (Substance Use Disorder) Counselor |
| LPC001626 | GA | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1250467200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1250467200000",
"number": "1114159696",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9635 VENTANA WAY",
"address_2": "SUITE 101",
"city": "JOHNS CREEK",
"state": "GA",
"postal_code": "300228620",
"telephone_number": "770-495-6339",
"fax_number": "770-495-6338"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9635 VENTANA WAY",
"address_2": "SUITE 101",
"city": "JOHNS CREEK",
"state": "GA",
"postal_code": "300228620",
"telephone_number": "770-495-6339",
"fax_number": "770-495-6338"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TILLIS",
"first_name": "DAVID",
"middle_name": "ROGER",
"name_prefix": "Mr.",
"credential": "LPC, NCC, MAC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2009-08-17",
"last_updated": "2009-08-17",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "GA",
"license": "MAC030853",
"primary": false
},
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "GA",
"license": "LPC001626",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Johns Creek, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.