Provider Demographics
NPI:1407380686
Name:LILLY, BIANCA (MA, BCBA, LBA)
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602
Mailing Address - Country:US
Mailing Address - Phone:337-882-2100
Mailing Address - Fax:337-882-2111
Practice Address - Street 1:226 W PRIEN LAKE RD STE 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8781
Practice Address - Country:US
Practice Address - Phone:337-882-2100
Practice Address - Fax:337-882-2111
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11725428103K00000X
LA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2459112Medicaid