Provider Demographics
NPI:1396011086
Name:WORRELL, TILLIE SUE
Entity Type:Individual
Prefix:
First Name:TILLIE
Middle Name:SUE
Last Name:WORRELL
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 1:7700 HARRIER AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4442
Mailing Address - Country:US
Mailing Address - Phone:505-659-1106
Mailing Address - Fax:
Practice Address - Street 1:2218 SOUTHERN BLVD SE STE 14
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3750
Practice Address - Country:US
Practice Address - Phone:505-994-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health