Provider Demographics
NPI:1558444919
Name:LILLY, DOROTHY MARIE (RLCSW)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:MARIE
Last Name:LILLY
Suffix:
Gender:F
Credentials:RLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 SYCAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3158
Mailing Address - Country:US
Mailing Address - Phone:631-689-1141
Mailing Address - Fax:631-928-8100
Practice Address - Street 1:14 E BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1400
Practice Address - Country:US
Practice Address - Phone:631-689-1141
Practice Address - Fax:631-928-8100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04337011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNG9901Medicare ID - Type Unspecified