Provider Demographics
NPI:1952475501
Name:TILLIS, CAMILLE A
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:A
Last Name:TILLIS
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 1:1553 W. 122 PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643
Mailing Address - Country:US
Mailing Address - Phone:708-422-4441
Mailing Address - Fax:708-422-2122
Practice Address - Street 1:4425 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-7221
Practice Address - Country:US
Practice Address - Phone:708-422-4441
Practice Address - Fax:708-422-2122
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003757225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist