Provider Demographics
NPI:1215938428
Name:LILLY, BOBBIE H (PHD)
Entity type:Individual
Prefix:
First Name:BOBBIE
Middle Name:H
Last Name:LILLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 GRANBURY ST
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-5752
Mailing Address - Country:US
Mailing Address - Phone:817-645-3328
Mailing Address - Fax:817-558-3203
Practice Address - Street 1:1011 GRANBURY ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-5752
Practice Address - Country:US
Practice Address - Phone:817-645-3328
Practice Address - Fax:817-558-3203
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00G50YMedicare ID - Type Unspecified