Provider Demographics
NPI:1437296266
Name:LILLY, SUSAN F (MS, MFT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:F
Last Name:LILLY
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56244 PAPAGO TRL
Mailing Address - Street 2:SUITE #5
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3285
Mailing Address - Country:US
Mailing Address - Phone:760-799-2219
Mailing Address - Fax:
Practice Address - Street 1:56244 PAPAGO TRL
Practice Address - Street 2:SUITE#5
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3285
Practice Address - Country:US
Practice Address - Phone:760-799-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist