Provider Demographics
NPI:1689288813
Name:LILYS PLACE FAMILY CENTER
Entity Type:Organization
Organization Name:LILYS PLACE FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER OF ED
Authorized Official - Phone:304-523-5459
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25706
Mailing Address - Country:US
Mailing Address - Phone:304-523-5459
Mailing Address - Fax:304-523-8341
Practice Address - Street 1:1235 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2904
Practice Address - Country:US
Practice Address - Phone:304-523-5459
Practice Address - Fax:304-523-8341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LILY'S PLACE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-04
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910005949Medicaid