Provider Demographics
NPI:1033205125
Name:LILLARD, RICHARD P (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
Last Name:LILLARD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W TRUMAN BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5752
Mailing Address - Country:US
Mailing Address - Phone:573-644-7909
Mailing Address - Fax:573-644-7908
Practice Address - Street 1:3405 W TRUMAN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5861
Practice Address - Country:US
Practice Address - Phone:573-864-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103TC1900X
MO2006033324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497174508Medicaid
224191545Medicare PIN