Provider Demographics
NPI:1619579158
Name:TILLEY, MARTHA ELIZABETH (MA, SSP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELIZABETH
Last Name:TILLEY
Suffix:
Gender:F
Credentials:MA, SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 OLD THAYER MILL RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NC
Mailing Address - Zip Code:27371-2009
Mailing Address - Country:US
Mailing Address - Phone:910-282-7927
Mailing Address - Fax:
Practice Address - Street 1:222 OLD THAYER MILL RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371-2009
Practice Address - Country:US
Practice Address - Phone:910-282-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA470535F103TS0200X
NC766899103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool