Provider Demographics
NPI:1811147499
Name:LILLY, MICHELLE MARIE (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:LILLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2S504 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6939
Mailing Address - Country:US
Mailing Address - Phone:630-696-2443
Mailing Address - Fax:
Practice Address - Street 1:2S504 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6939
Practice Address - Country:US
Practice Address - Phone:630-696-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007793103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071.007793OtherLICENSED PSYCHOLOGIST