Provider Demographics
NPI:1679233035
Name:LILLY, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:LILLY
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 1:475 S JOHN RODES BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1093
Mailing Address - Country:US
Mailing Address - Phone:321-241-1170
Mailing Address - Fax:321-241-1171
Practice Address - Street 1:475 S JOHN RODES BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1093
Practice Address - Country:US
Practice Address - Phone:321-241-1170
Practice Address - Fax:321-241-1171
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician