Provider Demographics
NPI:1669586517
Name:LILLY, ANTHONY EZRA (PSYD, HSPP)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:EZRA
Last Name:LILLY
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1044
Mailing Address - Country:US
Mailing Address - Phone:812-346-7744
Mailing Address - Fax:812-346-3815
Practice Address - Street 1:753 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1044
Practice Address - Country:US
Practice Address - Phone:812-346-7744
Practice Address - Fax:812-346-3815
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042033A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN050571023OtherFED TAX IDENTIFICATION
IN200805260AMedicaid
IN234160Medicare ID - Type Unspecified