Provider Demographics
NPI:1508164658
Name:LILLYSTONE, JEANETTE L (CTRS)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:L
Last Name:LILLYSTONE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2945
Mailing Address - Country:US
Mailing Address - Phone:248-398-4858
Mailing Address - Fax:
Practice Address - Street 1:1669 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-1230
Practice Address - Country:US
Practice Address - Phone:248-646-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist