Provider Demographics
NPI:1144643701
Name:TILLERY, VALERIE
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:TILLERY
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 1:4250 LAKELAND HIGHLANDS RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3113
Mailing Address - Country:US
Mailing Address - Phone:863-647-4303
Mailing Address - Fax:863-644-1326
Practice Address - Street 1:4250 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3113
Practice Address - Country:US
Practice Address - Phone:863-647-4303
Practice Address - Fax:863-644-1326
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist