NPIMap

Individual provider Active NPI

Ricardo David Tillery, MBA, LMSW, ICAADC

  • Clinical Social Worker
  • Lansing, MI
National Provider Identifier
1528380623
Registry record updated Sep 13, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
License
6801094835 Issued in MI
Practice address
3721 W Michigan Ave Ste 200
Lansing, MI 48917-3600
Phone
(517) 515-6176
NPI assigned
Feb 17, 2010
Last updated
Sep 13, 2020By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Sep 13, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X C-02622 MI
Social Worker 104100000X
Clinical Social Worker 1041C0700X 6801094835 MI Primary
Behavior Analyst 103K00000X

Addresses

Primary practice location

3721 W Michigan Ave Ste 200
Lansing, MI 48917-3600

Mailing address

3721 W Michigan Ave Ste 200
Lansing, MI 48917-3600
Phone (517) 515-6176

Other identifiers 1

IdentifierTypeStateIssuer
1396128088MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20171205002052 MI Practitioner - Clinical Social Worker 7214294974 Reassigns benefits to 2 organizations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Master of Business Administration

State licenses

LicenseStateTypeSpecialty
C-02622MIMDAddiction (Substance Use Disorder) Counselor

Practice roles

OrganizationSpecialtyStatusNew patients
Innovative Behavioral Health CurrentSince Jan 1, 2023 Accepting new patients
Innovative Home Health Services Current Accepting new patients
Care Attendants LLC Clinical Past Accepting new patients

Locations

3721 W Michigan Ave
Ste 200
Lansing, MI 48917
Phone (517) 481-6270

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1266364800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1599955200000",
    "number": "1528380623",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3721 W MICHIGAN AVE STE 200",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489173600",
            "telephone_number": "517-515-6176"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3721 W MICHIGAN AVE STE 200",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489173600",
            "telephone_number": "517-515-6176"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TILLERY",
        "first_name": "RICARDO",
        "middle_name": "DAVID",
        "name_prefix": "Mr.",
        "credential": "MBA, LMSW,  ICAADC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-02-17",
        "last_updated": "2020-09-13",
        "certification_date": "2020-09-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "MI",
            "license": "C-02622",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MI",
            "license": "6801094835",
            "primary": true
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1396128088",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lansing, MI

Sources for this page

Verify at the official NPI Registry.