Provider Demographics
NPI:1093894362
Name:TILLEY, KRISTY (AUD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:TILLEY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SOUTH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4812
Mailing Address - Country:US
Mailing Address - Phone:845-471-3490
Mailing Address - Fax:845-454-3004
Practice Address - Street 1:201 SOUTH AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4812
Practice Address - Country:US
Practice Address - Phone:845-471-3490
Practice Address - Fax:845-454-3004
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002118-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002118-1OtherAUDIOLOGIST LICENSE