Provider Demographics
NPI:1417543158
Name:LILLIA, MCKENZIE ELYSE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ELYSE
Last Name:LILLIA
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 1:1336 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6906
Mailing Address - Country:US
Mailing Address - Phone:609-579-9799
Mailing Address - Fax:
Practice Address - Street 1:437A HIGHWAY 601 S
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8918
Practice Address - Country:US
Practice Address - Phone:803-900-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPT.10512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist