Provider Demographics
NPI:1508873217
Name:TILLEY, KATHLEEN MARY (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:TILLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11959-1564
Mailing Address - Country:US
Mailing Address - Phone:631-653-3355
Mailing Address - Fax:
Practice Address - Street 1:33 MONTAUK HWY.
Practice Address - Street 2:
Practice Address - City:QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11959-1564
Practice Address - Country:US
Practice Address - Phone:631-653-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013361-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist