Provider Demographics
NPI:1962101527
Name:LILLY, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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 1:278 BUMPY RD
Mailing Address - Street 2:
Mailing Address - City:NIMITZ
Mailing Address - State:WV
Mailing Address - Zip Code:25978
Mailing Address - Country:US
Mailing Address - Phone:304-777-9049
Mailing Address - Fax:
Practice Address - Street 1:228 SHAMROCK LN
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8380
Practice Address - Country:US
Practice Address - Phone:304-497-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP009463701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical