Provider Demographics
NPI:1275169914
Name:LILLY, SUSANNE CAROLINE
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:CAROLINE
Last Name:LILLY
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 1:406 N RED HILL RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2018
Mailing Address - Country:US
Mailing Address - Phone:304-575-8540
Mailing Address - Fax:
Practice Address - Street 1:51 STREET OF DREAMS
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-1134
Practice Address - Country:US
Practice Address - Phone:304-224-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP009453431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical