Provider Demographics
NPI:1285013888
Name:LILLY, MARY KATHERINE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:LILLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 337
Mailing Address - Street 2:908 SCARBRO ROAD
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917
Mailing Address - Country:US
Mailing Address - Phone:304-574-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:908 SCARBRO ROAD
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917
Practice Address - Country:US
Practice Address - Phone:304-574-2905
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009403881041C0700X
TX1114361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical