Provider Demographics
NPI:1215104542
Name:LILLIS, JULIE A
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:A
Last Name:LILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 MANATEE BAY DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-2821
Mailing Address - Country:US
Mailing Address - Phone:561-307-3703
Mailing Address - Fax:
Practice Address - Street 1:1375 GATEWAY BLVD STE 32
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8304
Practice Address - Country:US
Practice Address - Phone:561-307-3703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14558101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherSOCIAL SECURITY NUMBER