Provider Demographics
NPI:1518921832
Name:LILLEY, JUDITH BONDERIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:BONDERIA
Last Name:LILLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CARL VINSON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-922-2365
Mailing Address - Fax:478-922-1778
Practice Address - Street 1:121 CARL VINSON PARKWAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-922-2365
Practice Address - Fax:478-922-1778
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA240831OtherBCBS
80BBQSMedicare ID - Type Unspecified