Provider Demographics
NPI:1770807950
Name:MUNAVU, LILY C (PHD)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:C
Last Name:MUNAVU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LILY
Other - Middle Name:C
Other - Last Name:MANICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1728 W MARINE VIEW DR STE 106
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2094
Practice Address - Country:US
Practice Address - Phone:425-339-5453
Practice Address - Fax:425-252-4441
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60073221103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006690Medicaid
WAPY60073221OtherLICENSE
WAG8890584Medicare PIN