Provider Demographics
NPI:1043921760
Name:HANSCOM, LILY
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:HANSCOM
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 1:4301 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2005
Mailing Address - Country:US
Mailing Address - Phone:520-795-0300
Mailing Address - Fax:520-795-8206
Practice Address - Street 1:4301 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2005
Practice Address - Country:US
Practice Address - Phone:520-795-0300
Practice Address - Fax:520-795-8206
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20594101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health