Provider Demographics
NPI:1043591639
Name:LILLIQUIST, BETHANY (PHD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LILLIQUIST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:AARONSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:333 E 43RD ST
Mailing Address - Street 2:LOBBY SUITE 1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-4831
Mailing Address - Country:US
Mailing Address - Phone:917-409-7637
Mailing Address - Fax:
Practice Address - Street 1:333 E 43RD ST
Practice Address - Street 2:LOBBY SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4831
Practice Address - Country:US
Practice Address - Phone:917-409-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist