Provider Demographics
NPI:1265909592
Name:TILUS, LYDIA-CARLIE BLAIN
Entity type:Individual
Prefix:MISS
First Name:LYDIA-CARLIE
Middle Name:BLAIN
Last Name:TILUS
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 1:400 E HILLSDALE BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2882
Mailing Address - Country:US
Mailing Address - Phone:909-758-6248
Mailing Address - Fax:
Practice Address - Street 1:225 CABRILLO HWY S STE 204C
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1738
Practice Address - Country:US
Practice Address - Phone:424-240-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
CA41590225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty