Provider Demographics
NPI:1225273881
Name:TILLEM, COURTNEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:TILLEM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 E 20TH ST
Mailing Address - Street 2:APT. 6E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1805
Mailing Address - Country:US
Mailing Address - Phone:516-647-2111
Mailing Address - Fax:
Practice Address - Street 1:237 EAST 20TH STREET
Practice Address - Street 2:APT. 6E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1805
Practice Address - Country:US
Practice Address - Phone:516-647-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018309-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist