Provider Demographics
NPI:1033149497
Name:MCBROOM, LILLIAN M (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:M
Last Name:MCBROOM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W EASTERDAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1623
Mailing Address - Country:US
Mailing Address - Phone:906-635-1508
Mailing Address - Fax:906-635-7369
Practice Address - Street 1:517 W EASTERDAY AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1623
Practice Address - Country:US
Practice Address - Phone:906-635-1508
Practice Address - Fax:906-635-7369
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010653421041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP34440017Medicare PIN