Healthcare Provider Details

I. General information

NPI: 1043921760
Provider Name (Legal Business Name): LILY HANSCOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 N WILMOT RD STE B
TUCSON AZ
85711-1712
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-290-1100
  • Fax: 520-290-8997
Mailing address:
  • Phone: 520-290-1100
  • Fax: 520-290-8997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLPC-20594
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-20594
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-20594
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: