Provider Demographics
NPI:1194593293
Name:LILLIS, MARYANNE (LPC)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:LILLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11828 W CENTRAL AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5178
Mailing Address - Country:US
Mailing Address - Phone:316-613-3995
Mailing Address - Fax:
Practice Address - Street 1:11828 W CENTRAL AVE STE 104
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-5178
Practice Address - Country:US
Practice Address - Phone:316-613-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLPC0445101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health