Provider Demographics
NPI:1326862822
Name:KLINGSPORN, LILLY ANN
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:ANN
Last Name:KLINGSPORN
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 1:2505 N PROSPECT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4127
Mailing Address - Country:US
Mailing Address - Phone:414-702-3890
Mailing Address - Fax:
Practice Address - Street 1:11431 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3462
Practice Address - Country:US
Practice Address - Phone:262-518-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8202226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health