Healthcare Provider Details

I. General information

NPI: 1164619748
Provider Name (Legal Business Name): TANYA M CILLI OT-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 LONGVIEW DR SUITE C
JONESBORO AR
72401-5919
US

IV. Provider business mailing address

2811 LONGVIEW DR SUITE C
JONESBORO AR
72401-5919
US

V. Phone/Fax

Practice location:
  • Phone: 870-974-9114
  • Fax: 870-974-9184
Mailing address:
  • Phone: 870-974-9114
  • Fax: 870-974-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A495
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: