Provider Demographics
NPI:1346312808
Name:LILLICH, MARY HELEN (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HELEN
Last Name:LILLICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:LILLICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:101 FALLS RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2612
Mailing Address - Country:US
Mailing Address - Phone:262-375-8441
Mailing Address - Fax:262-546-0005
Practice Address - Street 1:101 FALLS RD
Practice Address - Street 2:SUITE 404
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2612
Practice Address - Country:US
Practice Address - Phone:262-375-8441
Practice Address - Fax:262-546-0005
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1665057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist