Provider Demographics
NPI:1619604428
Name:HETZLER, LILY
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:HETZLER
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 1:117 DOBBIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2803
Mailing Address - Country:US
Mailing Address - Phone:929-399-7115
Mailing Address - Fax:
Practice Address - Street 1:117 DOBBIN ST STE 210
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-2803
Practice Address - Country:US
Practice Address - Phone:646-881-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY120355-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty