Provider Demographics
NPI:1902273014
Name:TILLEY, KENT D (MDIV, NCCFBPPC)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:D
Last Name:TILLEY
Suffix:
Gender:M
Credentials:MDIV, NCCFBPPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GARRISON DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3204
Mailing Address - Country:US
Mailing Address - Phone:704-616-4226
Mailing Address - Fax:
Practice Address - Street 1:112 GARRISON DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3204
Practice Address - Country:US
Practice Address - Phone:704-616-4226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC#70101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral