Healthcare Provider Details

I. General information

NPI: 1336696251
Provider Name (Legal Business Name): CHANA TILSON DR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BROAD STREET SUITE 1408
NEW YORK NY
10004
US

IV. Provider business mailing address

30 BROAD STREET SUITE 1408
NEW YORK NY
10004
US

V. Phone/Fax

Practice location:
  • Phone: 212-512-0860
  • Fax: 212-512-0861
Mailing address:
  • Phone: 212-512-0860
  • Fax: 212-512-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number71000813
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number000813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: