Provider Demographics
NPI:1184156457
Name:TILLMAN, KRISTOPHER GLENN (DPT)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:GLENN
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10980 GRANTCHESTER WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6097
Mailing Address - Country:US
Mailing Address - Phone:877-772-6505
Mailing Address - Fax:
Practice Address - Street 1:1100 E 33RD ST STE 105
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-6795
Practice Address - Country:US
Practice Address - Phone:410-366-0791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist