Provider Demographics
NPI:1477582617
Name:TILLEMAN, BETTY GAIL (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:GAIL
Last Name:TILLEMAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 S GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3013
Mailing Address - Country:US
Mailing Address - Phone:417-864-7854
Mailing Address - Fax:
Practice Address - Street 1:1111 N GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-2125
Practice Address - Country:US
Practice Address - Phone:417-865-2815
Practice Address - Fax:417-575-5494
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer