Healthcare Provider Details

I. General information

NPI: 1760176721
Provider Name (Legal Business Name): LAUREN MADDOX TILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 BROOK PARK PL
FOREST VA
24551-2766
US

IV. Provider business mailing address

316 BROOK PARK PL
FOREST VA
24551-2766
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-0877
  • Fax: 434-433-9131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-54188
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: