Provider Demographics
NPI:1770122640
Name:LILLY, EMMA J
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:J
Last Name:LILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73-4282 KEOKEO ST # B
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-9500
Mailing Address - Country:US
Mailing Address - Phone:415-328-6478
Mailing Address - Fax:
Practice Address - Street 1:16-566 KEAAU PAHOA RD # 188-111
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8137
Practice Address - Country:US
Practice Address - Phone:415-328-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-80655106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician