Provider Demographics
NPI:1720884646
Name:TATE, LILLIE
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:TATE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 RADCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5116
Mailing Address - Country:US
Mailing Address - Phone:618-920-0454
Mailing Address - Fax:
Practice Address - Street 1:337 RADCLIFF RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5116
Practice Address - Country:US
Practice Address - Phone:618-920-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.116015104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker