MEDICARE: VIRGINIA TILLERY NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1164226569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA TILLERY NCC

Provider Business Mailing Address
First Line	:	1005 SCOTT TOWN CTR # 1012
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-2356
Country	:	US
Telephone Number	:	814-317-6576
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 SCOTT TOWN CTR # 1012
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-2356
Country	:	US
Telephone Number	:	814-317-6576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2025
Last Update Date	:	04/03/2025

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