Provider Demographics
NPI:1427940642
Name:LILLY, LANDON (MA)
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:LILLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 MAPLE FORK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-9208
Mailing Address - Country:US
Mailing Address - Phone:304-712-1336
Mailing Address - Fax:
Practice Address - Street 1:221 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2609
Practice Address - Country:US
Practice Address - Phone:681-282-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health