Healthcare Provider Details

I. General information

NPI: 1265909592
Provider Name (Legal Business Name): MISS LYDIA-CARLIE BLAIN TILUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CABRILLO HWY S STE 204C
HALF MOON BAY CA
94019-1738
US

IV. Provider business mailing address

400 E HILLSDALE BLVD APT 208
SAN MATEO CA
94403-2882
US

V. Phone/Fax

Practice location:
  • Phone: 424-240-3691
  • Fax:
Mailing address:
  • Phone: 909-758-6248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number41590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: