Provider Demographics
NPI:1497442578
Name:LILLY, KA'NYSHA
Entity Type:Individual
Prefix:
First Name:KA'NYSHA
Middle Name:
Last Name:LILLY
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 1:3640 S CEDAR ST STE M
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-5700
Mailing Address - Country:US
Mailing Address - Phone:253-478-0827
Mailing Address - Fax:
Practice Address - Street 1:3640 S CEDAR ST STE M
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5700
Practice Address - Country:US
Practice Address - Phone:253-478-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)