Provider Demographics
NPI:1366942781
Name:LILLY, LATONYA
Entity type:Individual
Prefix:MISS
First Name:LATONYA
Middle Name:
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 1:306 N KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1870
Mailing Address - Country:US
Mailing Address - Phone:312-914-0611
Mailing Address - Fax:312-919-0324
Practice Address - Street 1:9530 PERRY HALL BLVD APT 202
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1337
Practice Address - Country:US
Practice Address - Phone:443-725-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician