Healthcare Provider Details

I. General information

NPI: 1801435797
Provider Name (Legal Business Name): CONTRICKA TOWANA TILLQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2019
Last Update Date: 12/25/2019
Certification Date: 12/25/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 TAVISTOCK LAKES BLVD STE 400
ORLANDO FL
32827-7593
US

IV. Provider business mailing address

177 SOUTHAMPTON DR
KISSIMMEE FL
34744-8445
US

V. Phone/Fax

Practice location:
  • Phone: 407-970-0824
  • Fax: 321-235-5506
Mailing address:
  • Phone: 863-279-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT10334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: