Provider Demographics
NPI:1154715027
Name:SHORTER, LILLY MARIE (LCAS 21705)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:MARIE
Last Name:SHORTER
Suffix:
Gender:F
Credentials:LCAS 21705
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 GRANGER RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8060
Mailing Address - Country:US
Mailing Address - Phone:910-578-3134
Mailing Address - Fax:
Practice Address - Street 1:86 THREE HUNT DRIVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372
Practice Address - Country:US
Practice Address - Phone:910-522-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS 21705101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)