Provider Demographics
NPI:1780090175
Name:TILLIS, BRITTANI
Entity type:Individual
Prefix:
First Name:BRITTANI
Middle Name:
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 1:7905 MARVIN D LOVE FWY APT 621
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3476
Mailing Address - Country:US
Mailing Address - Phone:469-585-6557
Mailing Address - Fax:
Practice Address - Street 1:3314 W KIEST BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75233-2102
Practice Address - Country:US
Practice Address - Phone:214-623-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT118707225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist