Provider Demographics
NPI:1962087510
Name:LILLY, STEPHANIE THRESSA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:THRESSA
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 COOL LN
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-8704
Mailing Address - Country:US
Mailing Address - Phone:304-763-7026
Mailing Address - Fax:
Practice Address - Street 1:1289 ROBERT C BYRD DR.,
Practice Address - Street 2:SUITE 4
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827-2580
Practice Address - Country:US
Practice Address - Phone:304-253-8979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator