Provider Demographics
NPI:1366427320
Name:LILLY, HAROLD GINO (LCAS)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:GINO
Last Name:LILLY
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 S COX ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-6461
Mailing Address - Country:US
Mailing Address - Phone:336-626-9139
Mailing Address - Fax:336-683-8256
Practice Address - Street 1:723 S COX ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-6461
Practice Address - Country:US
Practice Address - Phone:336-626-9139
Practice Address - Fax:336-683-8256
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111760Medicaid