Provider Demographics
NPI:1154153336
Name:STREAKER, LILLIAN (LGPAT)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:STREAKER
Suffix:
Gender:F
Credentials:LGPAT
Other - Prefix:MISS
Other - First Name:LILLIAN
Other - Middle Name:
Other - Last Name:STREAKER
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:LGPAT
Mailing Address - Street 1:710 PIN OAK RD
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3609
Mailing Address - Country:US
Mailing Address - Phone:443-223-7069
Mailing Address - Fax:
Practice Address - Street 1:8181 MAIN ST APT 2
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4929
Practice Address - Country:US
Practice Address - Phone:410-505-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATG336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health