Provider Demographics
NPI:1922560671
Name:TILLERY, CRYSTAL (COTA, CDP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:TILLERY
Suffix:
Gender:F
Credentials:COTA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35057 MAYER RD
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:TX
Mailing Address - Zip Code:77445-4372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5600 CYPRESSWOOD DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-8691
Practice Address - Country:US
Practice Address - Phone:844-446-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211995224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant