Provider Demographics
NPI:1124519145
Name:TILLIS, MALLORY LYNN (SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNN
Last Name:TILLIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:15701 E 1ST AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-9037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6820 SOUTHPOINT PKWY STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6277
Practice Address - Country:US
Practice Address - Phone:039-888-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14700235Z00000X
COSLP.0005885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist