Provider Demographics
NPI:1780294637
Name:TILLAGE, CARLYN MARIE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:CARLYN
Middle Name:MARIE
Last Name:TILLAGE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BRADDOCK PL APT 1016
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1674
Mailing Address - Country:US
Mailing Address - Phone:804-832-6802
Mailing Address - Fax:
Practice Address - Street 1:6231 LEESBURG PIKE STE 500
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2102
Practice Address - Country:US
Practice Address - Phone:703-536-1817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119-008699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist