Provider Demographics
NPI:1013083096
Name:LILLY, MARIAN EVELYN (LPC)
Entity type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:EVELYN
Last Name:LILLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 E JUDD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2447
Mailing Address - Country:US
Mailing Address - Phone:616-754-6085
Mailing Address - Fax:
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-356-6247
Practice Address - Fax:616-732-6392
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008098101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509106890Medicare UPIN