Provider Demographics
NPI:1881189124
Name:DETTLE, LILY
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:DETTLE
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 1:311 WINN CT
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-3011
Mailing Address - Country:US
Mailing Address - Phone:715-520-3634
Mailing Address - Fax:
Practice Address - Street 1:311 WINN CT
Practice Address - Street 2:
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-3011
Practice Address - Country:US
Practice Address - Phone:715-520-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4671-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist