Provider Demographics
NPI:1104081942
Name:LILLIE HOUSE
Entity type:Organization
Organization Name:LILLIE HOUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HIGGENBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:414-732-4253
Mailing Address - Street 1:4618 KINZIE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2212
Mailing Address - Country:US
Mailing Address - Phone:262-634-6781
Mailing Address - Fax:
Practice Address - Street 1:4618 KINZIE AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-2212
Practice Address - Country:US
Practice Address - Phone:262-634-6781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home