Provider Demographics
NPI:1154534527
Name:TILLOU, DEBRA A (DC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:TILLOU
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:WALDOBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04572-0625
Mailing Address - Country:US
Mailing Address - Phone:207-832-6347
Mailing Address - Fax:207-832-4664
Practice Address - Street 1:290 BREMEN RD
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572
Practice Address - Country:US
Practice Address - Phone:207-832-6347
Practice Address - Fax:207-832-4664
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME129130099Medicaid
022301OtherANTHEM
T06443Medicare UPIN
ME129130099Medicaid