Provider Demographics
NPI:1639261100
Name:TILLEY, CAROL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:TILLEY
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 1:3014 MILLSTREAM CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-1520
Mailing Address - Country:US
Mailing Address - Phone:703-620-5102
Mailing Address - Fax:
Practice Address - Street 1:11244 WAPLES MILL RD
Practice Address - Street 2:SUITE K
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6040
Practice Address - Country:US
Practice Address - Phone:703-218-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002060174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist