Provider Demographics
NPI:1417212697
Name:LILLY, BRANDON ALAN (MA)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:ALAN
Last Name:LILLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13008 E 90TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4752
Mailing Address - Country:US
Mailing Address - Phone:918-274-8742
Mailing Address - Fax:
Practice Address - Street 1:13008 E 90TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4752
Practice Address - Country:US
Practice Address - Phone:918-274-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health