Provider Demographics
NPI:1245779388
Name:TILLMAN, LAURA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BROADWAY
Mailing Address - Street 2:APT D19C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-8726
Mailing Address - Country:US
Mailing Address - Phone:914-844-1667
Mailing Address - Fax:
Practice Address - Street 1:3333 BROADWAY
Practice Address - Street 2:APT D19C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-8726
Practice Address - Country:US
Practice Address - Phone:914-844-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021258225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist