Provider Demographics
NPI:1447733993
Name:LILLY, BONNIE FAYE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:FAYE
Last Name:LILLY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 BROOKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4401
Mailing Address - Country:US
Mailing Address - Phone:361-446-6405
Mailing Address - Fax:
Practice Address - Street 1:13330 LEOPARD ST STE 34
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4481
Practice Address - Country:US
Practice Address - Phone:361-446-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health