Provider Demographics
NPI:1902509003
Name:TILLMON, TEZLYNN
Entity Type:Individual
Prefix:
First Name:TEZLYNN
Middle Name:
Last Name:TILLMON
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 1:20251 N 75TH AVE APT 2065
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7906
Mailing Address - Country:US
Mailing Address - Phone:918-815-6257
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE STE F100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0871
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist