Provider Demographics
NPI:1306358775
Name:BLOCK, LILLIAN ROSE
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:ROSE
Last Name:BLOCK
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 1:6852 AUGUSTA BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-4524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4518 S MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2306
Practice Address - Country:US
Practice Address - Phone:813-693-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician