Provider Demographics
NPI:1609251917
Name:LILLY, ERIN MISSY (LCSW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MISSY
Last Name:LILLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MISSY
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2455
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-2455
Mailing Address - Country:US
Mailing Address - Phone:575-525-8484
Mailing Address - Fax:505-554-3435
Practice Address - Street 1:3321B CANDELARIA RD NE STE 407
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1971
Practice Address - Country:US
Practice Address - Phone:575-525-8484
Practice Address - Fax:505-554-3435
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-09188101YM0800X
1041C0700X
NMC-113121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87439786Medicaid
NM02821575Medicaid