Provider Demographics
NPI:1588706162
Name:COULTER, LILA (PHD)
Entity type:Individual
Prefix:DR
First Name:LILA
Middle Name:
Last Name:COULTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 WARD ST
Mailing Address - Street 2:SUITE #105
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1124
Mailing Address - Country:US
Mailing Address - Phone:510-649-0207
Mailing Address - Fax:
Practice Address - Street 1:2340 WARD ST
Practice Address - Street 2:SUITE #105
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1124
Practice Address - Country:US
Practice Address - Phone:510-649-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11391103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL113910Medicare ID - Type Unspecified