Provider Demographics
NPI:1093229957
Name:LILLIE, ANNA IRIS (CDCA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:IRIS
Last Name:LILLIE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:IRIS
Other - Last Name:KNOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCDCII
Mailing Address - Street 1:1909 E 89TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2007
Mailing Address - Country:US
Mailing Address - Phone:216-231-3772
Mailing Address - Fax:216-231-5040
Practice Address - Street 1:1909 E 89TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2007
Practice Address - Country:US
Practice Address - Phone:216-231-3772
Practice Address - Fax:216-231-5040
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140521101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH346579390Medicaid