Provider Demographics
NPI:1962066563
Name:LILLAS, CONSTANCE M (RN, MFT, PHD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:M
Last Name:LILLAS
Suffix:
Gender:F
Credentials:RN, MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 N LOS ROBLES AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1411 N LOS ROBLES AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2140
Practice Address - Country:US
Practice Address - Phone:626-577-9332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA317432163W00000X
CA22318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse