Provider Demographics
NPI:1790127520
Name:LILLY, TYVONDER M (MHSA, QP)
Entity Type:Individual
Prefix:
First Name:TYVONDER
Middle Name:M
Last Name:LILLY
Suffix:
Gender:F
Credentials:MHSA, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 HUFFMAN MILL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8862
Mailing Address - Country:US
Mailing Address - Phone:336-538-6990
Mailing Address - Fax:336-538-6991
Practice Address - Street 1:1159 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8862
Practice Address - Country:US
Practice Address - Phone:336-538-6990
Practice Address - Fax:336-538-6991
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health