Provider Demographics
NPI:1467589986
Name:LILLY, DAVID C (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:LILLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 S FREEPORT RD # 2E
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6145
Mailing Address - Country:US
Mailing Address - Phone:207-865-9692
Mailing Address - Fax:207-865-9241
Practice Address - Street 1:174 S FREEPORT RD # 2E
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6145
Practice Address - Country:US
Practice Address - Phone:207-865-9692
Practice Address - Fax:207-865-9241
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS107103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME039291OtherANTHEM
ME328740099Medicaid
ME328740099Medicaid