Provider Demographics
NPI:1336876432
Name:TILLMAN, DEVAN MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:DEVAN
Middle Name:MICHELLE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-3026
Mailing Address - Country:US
Mailing Address - Phone:870-352-6301
Mailing Address - Fax:
Practice Address - Street 1:201 N CLIFTON ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-3026
Practice Address - Country:US
Practice Address - Phone:870-352-6301
Practice Address - Fax:870-352-6483
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA3795225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant