Provider Demographics
NPI:1073125597
Name:BEACH, LILLIAN
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:BEACH
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 1:6525 160TH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2540
Mailing Address - Country:US
Mailing Address - Phone:347-885-8671
Mailing Address - Fax:
Practice Address - Street 1:178 KEARNEY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-3421
Practice Address - Country:US
Practice Address - Phone:347-885-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst