Provider Demographics
NPI:1952421646
Name:LILLY-QUEEN, ASHLEY BROOKE (MOT)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:BROOKE
Last Name:LILLY-QUEEN
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-0745
Mailing Address - Country:US
Mailing Address - Phone:304-465-8068
Mailing Address - Fax:
Practice Address - Street 1:100 PARK STREET
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-6262
Practice Address - Fax:304-732-7226
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2009-02-04
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2009-02-04
Provider Licenses
StateLicense IDTaxonomies
WV1234225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003848Medicaid