Provider Demographics
NPI:1396534830
Name:LILLARD, GRALY
Entity type:Individual
Prefix:
First Name:GRALY
Middle Name:
Last Name:LILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 CORDELL DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45439-3272
Mailing Address - Country:US
Mailing Address - Phone:937-266-0774
Mailing Address - Fax:
Practice Address - Street 1:3455 DAYTON XENIA RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2730
Practice Address - Country:US
Practice Address - Phone:937-266-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.024700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist