Provider Demographics
NPI:1003437815
Name:TILLMAN, CHARLITA
Entity Type:Individual
Prefix:
First Name:CHARLITA
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 1:20727 FERNWICK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-1745
Mailing Address - Country:US
Mailing Address - Phone:219-545-8119
Mailing Address - Fax:
Practice Address - Street 1:2000 HOLLY HALL ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-4032
Practice Address - Country:US
Practice Address - Phone:713-799-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN212295224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant