Provider Demographics
NPI:1104274042
Name:TILLY, ANDREW (MSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TILLY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4727 HARRIET LN
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017
Mailing Address - Country:US
Mailing Address - Phone:610-751-9492
Mailing Address - Fax:
Practice Address - Street 1:1650 BROADWAY
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-3904
Practice Address - Country:US
Practice Address - Phone:610-799-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW123997171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator