Provider Demographics
NPI:1427193374
Name:TILLISON, EDGAR
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:TILLISON
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 1:2601 E. VICTORIA STREET
Mailing Address - Street 2:SPC #221
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-7027
Mailing Address - Country:US
Mailing Address - Phone:310-631-1243
Mailing Address - Fax:310-631-1243
Practice Address - Street 1:1055 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5804
Practice Address - Country:US
Practice Address - Phone:310-868-5379
Practice Address - Fax:310-868-5397
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 38333106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist