Healthcare Provider Details

I. General information

NPI: 1982205167
Provider Name (Legal Business Name): LILY GARCILAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LINCOLN ST
EMPORIA KS
66801-2449
US

IV. Provider business mailing address

1000 LINCOLN ST
EMPORIA KS
66801-2449
US

V. Phone/Fax

Practice location:
  • Phone: 620-343-2211
  • Fax: 620-342-1021
Mailing address:
  • Phone: 620-343-2211
  • Fax: 620-342-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number03018
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: