Provider Demographics
NPI:1043557192
Name:TILLERY, TRAVIS J (BS ECONOMICS/HEALTH)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:TILLERY
Suffix:
Gender:M
Credentials:BS ECONOMICS/HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 NE 70TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-5714
Mailing Address - Country:US
Mailing Address - Phone:786-972-9120
Mailing Address - Fax:
Practice Address - Street 1:840 NE 70TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-5714
Practice Address - Country:US
Practice Address - Phone:786-972-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator