Provider Demographics
NPI:1215100391
Name:TILLEY, LAURA RENEE (AUD, CCC/A)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:RENEE
Last Name:TILLEY
Suffix:
Gender:F
Credentials:AUD, CCC/A
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:RENEE
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-335-2597
Practice Address - Street 1:6809 W NW HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-4202
Practice Address - Country:US
Practice Address - Phone:214-691-5466
Practice Address - Fax:214-691-7250
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60525231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB144437Medicare PIN