Healthcare Provider Details

I. General information

NPI: 1215097266
Provider Name (Legal Business Name): KATHY F. TILLEY MA, RN, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 INDIAN SCHOOL RD NE STE. 101-A
ALBUQUERQUE NM
87112-2884
US

IV. Provider business mailing address

9301 INDIAN SCHOOL RD NE STE. 101-A
ALBUQUERQUE NM
87112-2884
US

V. Phone/Fax

Practice location:
  • Phone: 505-480-9782
  • Fax: 505-271-1714
Mailing address:
  • Phone: 505-480-9782
  • Fax: 505-271-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1647
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: