Provider Demographics
NPI:1407406150
Name:TILLEY, DAVID BRADLEY
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRADLEY
Last Name:TILLEY
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 1:811 CROSS TIMBERS DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3842
Mailing Address - Country:US
Mailing Address - Phone:804-307-0125
Mailing Address - Fax:
Practice Address - Street 1:200 COUNTRY BROOK DR APT 2110
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2135
Practice Address - Country:US
Practice Address - Phone:817-337-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2150398225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant