Provider Demographics
NPI:1225733553
Name:TILLISON, TERRANCE
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:TILLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 KENNEBEC ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3308
Mailing Address - Country:US
Mailing Address - Phone:202-880-4987
Mailing Address - Fax:
Practice Address - Street 1:1100 KENNEBEC ST APT 4D
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3308
Practice Address - Country:US
Practice Address - Phone:202-880-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator