Healthcare Provider Details

I. General information

NPI: 1588922140
Provider Name (Legal Business Name): DONALD AMOS LILLEY LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TULLY RD SUITE F
MODESTO CA
95350-2946
US

IV. Provider business mailing address

12414 MILLS ST
GROVELAND CA
95321-9322
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1750
  • Fax:
Mailing address:
  • Phone: 209-962-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberLMFT 19577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: