Healthcare Provider Details

I. General information

NPI: 1154599629
Provider Name (Legal Business Name): BONNIE LILLIS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 NATIONAL DR
GLASTONBURY CT
06033-4371
US

IV. Provider business mailing address

50 GRISWOLD ST
NEW BRITAIN CT
06052-2008
US

V. Phone/Fax

Practice location:
  • Phone: 860-430-5515
  • Fax: 860-430-9754
Mailing address:
  • Phone: 860-224-5267
  • Fax: 860-224-5752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: