Healthcare Provider Details

I. General information

NPI: 1447623012
Provider Name (Legal Business Name): ERIN R TILLY RMT, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 3RD AVE
FAIRBANKS AK
99701-4737
US

IV. Provider business mailing address

3842 HARDLUCK DR
FAIRBANKS AK
99709-5976
US

V. Phone/Fax

Practice location:
  • Phone: 907-888-2344
  • Fax: 907-451-6699
Mailing address:
  • Phone: 907-888-2344
  • Fax: 907-451-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number104002
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number006369
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: