Provider Demographics
NPI:1467599159
Name:TILLERY, KIM L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:L
Last Name:TILLERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CENTRAL AVE
Mailing Address - Street 2:SUNY AT FREDONIA
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1127
Mailing Address - Country:US
Mailing Address - Phone:716-673-3203
Mailing Address - Fax:716-673-3235
Practice Address - Street 1:280 CENTRAL AVE
Practice Address - Street 2:SUNY AT FREDONIA
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1127
Practice Address - Country:US
Practice Address - Phone:716-673-3203
Practice Address - Fax:716-673-3235
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0014251237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter