Provider Demographics
NPI:1790942167
Name:KEUNG, TILLY K
Entity Type:Individual
Prefix:MS
First Name:TILLY
Middle Name:K
Last Name:KEUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14815 AVERY RANCH BLVD UNIT 2902
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-4049
Mailing Address - Country:US
Mailing Address - Phone:512-680-1669
Mailing Address - Fax:
Practice Address - Street 1:2120 N MAYS ST STE 230
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2108
Practice Address - Country:US
Practice Address - Phone:512-238-2903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
TXDT81145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist