MEDICARE: DR. LAURA RENEE TILLEY AUD, CCC/A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	60525	TX
2	237600000X	Audiologist-Hearing Aid Fitter	60525	TX

General Provider Information

NPI Number	:	1215100391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA RENEE TILLEY AUD, CCC/A

Provider Business Mailing Address
First Line	:	400 S HENDERSON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-1017
Country	:	US
Telephone Number	:	817-335-2583
Fax Number	:	817-335-2597

Provider Business Practice Location Address
First Line	:	6809 W NW HWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-4202
Country	:	US
Telephone Number	:	214-691-5466
Fax Number	:	214-691-7250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	04/25/2012

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