Provider Demographics
NPI:1164134110
Name:SCOTT, LILLIE LEE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:LEE
Last Name:SCOTT
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 1:1 RICHMOND SQ # 333C
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5139
Mailing Address - Country:US
Mailing Address - Phone:401-441-5834
Mailing Address - Fax:
Practice Address - Street 1:1 RICHMOND SQ # 333C
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5139
Practice Address - Country:US
Practice Address - Phone:401-441-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI13762768321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI882988962Medicaid