Provider Demographics
NPI:1295226363
Name:TILLIS, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:TILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5157
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-5157
Mailing Address - Country:US
Mailing Address - Phone:209-572-2589
Mailing Address - Fax:209-572-1461
Practice Address - Street 1:9355 E STOCKTON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9476
Practice Address - Country:US
Practice Address - Phone:916-683-1109
Practice Address - Fax:916-683-1140
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17-28902106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician