Healthcare Provider Details

I. General information

NPI: 1003626581
Provider Name (Legal Business Name): AT4K TEXAS PROVIDERS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 02/07/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S MAIN ST STE 103
GRAPEVINE TX
76051-7531
US

IV. Provider business mailing address

112 WALNUT BLVD UNIT 308
ROCHESTER MI
48307-2317
US

V. Phone/Fax

Practice location:
  • Phone: 817-310-5510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHRIS TILLOTSON
Title or Position: CEO
Credential:
Phone: 248-770-9929