Provider Demographics
NPI:1487606885
Name:LILJEBERG, BETSY DORIA (PSYNP)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:DORIA
Last Name:LILJEBERG
Suffix:
Gender:F
Credentials:PSYNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1930
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:1427 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4343
Practice Address - Country:US
Practice Address - Phone:315-738-1428
Practice Address - Fax:315-738-1461
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400834-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039156Medicaid
NY00474180Medicaid
NY01039156Medicaid