Healthcare Provider Details

I. General information

NPI: 1043557192
Provider Name (Legal Business Name): TRAVIS J TILLERY B.S ECONOMICS/HEALTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 NE 70TH ST
MIAMI FL
33138-5714
US

IV. Provider business mailing address

840 NE 70TH ST
MIAMI FL
33138-5714
US

V. Phone/Fax

Practice location:
  • Phone: 786-972-9120
  • Fax:
Mailing address:
  • Phone: 786-972-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: