Provider Demographics
NPI:1245592302
Name:TILIS, AZA (SED (MA ED))
Entity Type:Individual
Prefix:
First Name:AZA
Middle Name:
Last Name:TILIS
Suffix:
Gender:F
Credentials:SED (MA ED)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 AVENUE Y
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2423
Mailing Address - Country:US
Mailing Address - Phone:718-332-8842
Mailing Address - Fax:718-332-8842
Practice Address - Street 1:2522 AVENUE Y
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2423
Practice Address - Country:US
Practice Address - Phone:718-332-8842
Practice Address - Fax:718-332-8842
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY900B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist