Provider Demographics
NPI:1992546444
Name:TILLMAN, MACKENZIE GRACE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14705 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1718
Mailing Address - Country:US
Mailing Address - Phone:443-578-6552
Mailing Address - Fax:
Practice Address - Street 1:8000 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer