Provider Demographics
NPI:1538407762
Name:CHILLIEST, TINA M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CHILLIEST
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 OLEAN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-4118
Mailing Address - Country:US
Mailing Address - Phone:508-344-0164
Mailing Address - Fax:
Practice Address - Street 1:24 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1273
Practice Address - Country:US
Practice Address - Phone:508-344-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8242235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist