Basic Information
| Provider Information | |||||||||
| NPI: | 1427193374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLISON | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 E. VICTORIA STREET | ||||||||
| Address2: | SPC #221 | ||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902207027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106311243 | ||||||||
| FaxNumber: | 3106311243 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 W VICTORIA ST | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902205804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108685379 | ||||||||
| FaxNumber: | 3108685397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 38333 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.