Provider Demographics
NPI:1578188165
Name:LILLY, THOMAS (MSW/LICSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:LILLY
Suffix:
Gender:M
Credentials:MSW/LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:INCHELIUM
Mailing Address - State:WA
Mailing Address - Zip Code:99138-0290
Mailing Address - Country:US
Mailing Address - Phone:509-722-7006
Mailing Address - Fax:
Practice Address - Street 1:39 SHORTCUT ROAD
Practice Address - Street 2:
Practice Address - City:INCHELIUM
Practice Address - State:WA
Practice Address - Zip Code:99138
Practice Address - Country:US
Practice Address - Phone:509-722-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000041591041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical