Provider Demographics
NPI:1962534487
Name:TILLEY, SHARON ELIZABETH BUBE (PHD)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ELIZABETH BUBE
Last Name:TILLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 6TH AVE
Mailing Address - Street 2:SUITE #5
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1567
Mailing Address - Country:US
Mailing Address - Phone:815-562-7775
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE
Practice Address - Street 2:SUITE #5
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1567
Practice Address - Country:US
Practice Address - Phone:815-562-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPE 10011103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7172000OtherBC BS PSYCHOLOGIST
IL7172000OtherBC BS PSYCHOLOGIST