Healthcare Provider Details

I. General information

NPI: 1477703114
Provider Name (Legal Business Name): TILLMAN PHYSICAL THERAPY & SPORTS TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 S LAKELINE BLVD SUITE 100
CEDAR PARK TX
78613-2964
US

IV. Provider business mailing address

2519 SOUTH LAKELINE BLVD SUITE 100
CEDAR PARK TX
78613-2964
US

V. Phone/Fax

Practice location:
  • Phone: 512-331-6200
  • Fax: 513-331-6384
Mailing address:
  • Phone: 512-331-6200
  • Fax: 513-331-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3106512
License Number StateTX

VIII. Authorized Official

Name: CHERLY FAUBION
Title or Position: DPT
Credential: DPT
Phone: 512-331-6200