Provider Demographics
NPI:1649746413
Name:TILLERY, ANNA (MA, BCBA, LPA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:TILLERY
Suffix:
Gender:F
Credentials:MA, BCBA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 DENADA PATH
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6039
Mailing Address - Country:US
Mailing Address - Phone:336-317-2844
Mailing Address - Fax:
Practice Address - Street 1:647 BRAWLEY SCHOOL RD STE 104
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6876
Practice Address - Country:US
Practice Address - Phone:704-703-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NC5446103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst