Provider Demographics
NPI:1730939356
Name:TILLYER, KELLY L (LMT, CD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:TILLYER
Suffix:
Gender:F
Credentials:LMT, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 MARTHA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1935
Mailing Address - Country:US
Mailing Address - Phone:973-862-1114
Mailing Address - Fax:
Practice Address - Street 1:1202 HADDONFIELD BERLIN RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4850
Practice Address - Country:US
Practice Address - Phone:973-862-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist