1851616239 NPI number — MS. REBECCA L TILLEY PSY D.

Table of content: MS. REBECCA L TILLEY PSY D. (NPI 1851616239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851616239 NPI number — MS. REBECCA L TILLEY PSY D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLEY
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PSY D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHLAU
Provider Other First Name:
REBECCA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851616239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 OLD CONGO RD
Provider Second Line Business Mailing Address:
SUITE F900
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-794-6557
Provider Business Mailing Address Fax Number:
501-794-6545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 OLD CONGO RD
Provider Second Line Business Practice Location Address:
SUITE F900
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-794-6557
Provider Business Practice Location Address Fax Number:
501-794-6545
Provider Enumeration Date:
03/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  10-04P , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10-04P . This is a "LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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