Provider Demographics
NPI:1790709897
Name:BLANK, LILY (PHD)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 W END AVE
Mailing Address - Street 2:#6A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7322
Mailing Address - Country:US
Mailing Address - Phone:917-363-0004
Mailing Address - Fax:
Practice Address - Street 1:910 W END AVE
Practice Address - Street 2:#1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3533
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02120414Medicaid
NYVM0341Medicare PIN