Provider Demographics
NPI:1972812279
Name:LILJESTRAND, BETH A (MS EDS)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:LILJESTRAND
Suffix:
Gender:F
Credentials:MS EDS
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:SLANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS EDS
Mailing Address - Street 1:3233 ARBOR HILL WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309
Mailing Address - Country:US
Mailing Address - Phone:850-661-5466
Mailing Address - Fax:850-894-0062
Practice Address - Street 1:3201 SHAMROCK ST S
Practice Address - Street 2:STE 103
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3321
Practice Address - Country:US
Practice Address - Phone:850-661-5466
Practice Address - Fax:850-894-0062
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7203101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008302000Medicaid