Provider Demographics
NPI:1316609191
Name:LILLY, TRACEYANN NICOLA
Entity type:Individual
Prefix:MS
First Name:TRACEYANN
Middle Name:NICOLA
Last Name:LILLY
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 1:9114 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5363
Mailing Address - Country:US
Mailing Address - Phone:718-408-7178
Mailing Address - Fax:
Practice Address - Street 1:9114 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5363
Practice Address - Country:US
Practice Address - Phone:718-408-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty