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General NPI Number Information
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NPI Number | 1295748804
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Entity Type | Individual
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Provider Name | KENT TILIS WORTHEN D.O.
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Gender | Male
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 01/13/2012
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Provider Practice Location Address
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Address Line | 26700 S US HIGHWAY 85 AZ CORRECTIONS LEWIS
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City | BUCKEYE
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State | AZ
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Zip | 85326-5024
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Country | US
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Telephone | 623-386-6160
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Fax |
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Provider Business Mailing Address
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Address Line | 26700 S US HIGHWAY 85 AZ CORRECTIONS LEWIS
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City | BUCKEYE
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State | AZ
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Zip | 85326-5024
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Country | US
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Telephone | 623-386-6160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 005741
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 4954099-1204
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License Number State | UT
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