Provider Demographics
NPI:1174226591
Name:MIRSKY, TILLIE
Entity type:Individual
Prefix:
First Name:TILLIE
Middle Name:
Last Name:MIRSKY
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 1:1400 TUCKER LN
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-9769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 TUCKER LN
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:MD
Practice Address - Zip Code:20861-9769
Practice Address - Country:US
Practice Address - Phone:240-393-2008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist