Healthcare Provider Details

I. General information

NPI: 1639008550
Provider Name (Legal Business Name): MRS. AMY RENEE TILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E ELM ST
WEST FRANKFORT IL
62896-2810
US

IV. Provider business mailing address

605 E ELM ST
WEST FRANKFORT IL
62896-2810
US

V. Phone/Fax

Practice location:
  • Phone: 618-364-6198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: