Provider Demographics
NPI:1093083081
Name:LILLIE, SANDRA LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:LEE
Last Name:LILLIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 VAQUERO WAY
Mailing Address - Street 2:
Mailing Address - City:EMERALD HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3152
Mailing Address - Country:US
Mailing Address - Phone:650-368-5802
Mailing Address - Fax:650-568-9800
Practice Address - Street 1:102 VAQUERO WAY
Practice Address - Street 2:
Practice Address - City:EMERALD HILLS
Practice Address - State:CA
Practice Address - Zip Code:94062-3152
Practice Address - Country:US
Practice Address - Phone:650-368-5802
Practice Address - Fax:650-568-9800
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical