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General NPI Number Information
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NPI Number | 1003626581
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Entity Type | Organization
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Legal Business Name | AT4K TEXAS PROVIDERS PLLC
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Dates
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Enumeration Date | 01/08/2025
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Last Update Date | 02/07/2025
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Provider Practice Location Address
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Address Line | 1100 S MAIN ST STE 103
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City | GRAPEVINE
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State | TX
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Zip | 76051-7531
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Country | US
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Telephone | 817-310-5510
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Fax |
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Provider Business Mailing Address
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Address Line | 112 WALNUT BLVD UNIT 308
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City | ROCHESTER
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State | MI
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Zip | 48307-2317
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CHRIS TILLOTSON
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Credential |
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Telephone | 248-770-9929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0006X
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Taxonomy Name | Developmental - Behavioral Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number |
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License Number State |
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