Provider Demographics
NPI:1689348351
Name:TILLIS, MARIA GUADALUPE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GUADALUPE
Last Name:TILLIS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7572 ASTER LN
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-0083
Mailing Address - Country:US
Mailing Address - Phone:760-500-2562
Mailing Address - Fax:
Practice Address - Street 1:503 W OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:LOS FRESNOS
Practice Address - State:TX
Practice Address - Zip Code:78566-3635
Practice Address - Country:US
Practice Address - Phone:956-233-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty