Provider Demographics
NPI:1225368954
Name:LILLIE, BROOKE (MA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:LILLIE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:DANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:130 DIVISION STREET
Mailing Address - Street 2:GRIFFIN HOSPITAL
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418
Mailing Address - Country:US
Mailing Address - Phone:203-732-7550
Mailing Address - Fax:203-732-1550
Practice Address - Street 1:130 DIVISION STREET
Practice Address - Street 2:GRIFFIN HOSPITAL
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418
Practice Address - Country:US
Practice Address - Phone:203-732-7550
Practice Address - Fax:203-732-1550
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00008OtherGRIFFIN HOSPITAL MEICARE #