Provider Demographics
NPI:1043818081
Name:TILLERY, SEAN A (PT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:A
Last Name:TILLERY
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:N2930 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5267
Practice Address - Country:US
Practice Address - Phone:920-787-5030
Practice Address - Fax:920-787-5372
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-5076225100000X
WI16686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist