Provider Demographics
NPI:1215953096
Name:LILL, KELLY DAWN (PHD, LMHC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAWN
Last Name:LILL
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13301 CASA VERDE CIR
Mailing Address - Street 2:
Mailing Address - City:ASTATULA
Mailing Address - State:FL
Mailing Address - Zip Code:34705-9393
Mailing Address - Country:US
Mailing Address - Phone:352-742-1346
Mailing Address - Fax:
Practice Address - Street 1:2000 PREVATT ST
Practice Address - Street 2:SUITE B
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6149
Practice Address - Country:US
Practice Address - Phone:352-589-0622
Practice Address - Fax:352-589-0276
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 7165101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767316700Medicaid