Provider Demographics
NPI:1508137928
Name:TILLOTSON, GAYLE LACIE (MS SLP - CCC)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:LACIE
Last Name:TILLOTSON
Suffix:
Gender:F
Credentials:MS SLP - CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 HUNTS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:RICHFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13835-2041
Mailing Address - Country:US
Mailing Address - Phone:607-849-6662
Mailing Address - Fax:
Practice Address - Street 1:974 HUNTS CORNERS RD
Practice Address - Street 2:
Practice Address - City:RICHFORD
Practice Address - State:NY
Practice Address - Zip Code:13835-2041
Practice Address - Country:US
Practice Address - Phone:607-849-6662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021611-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist