Healthcare Provider Details

I. General information

NPI: 1144910209
Provider Name (Legal Business Name): BROOKE SHACOLE LILLY M.ED, LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 CONN STREET
IVEL KY
41642
US

IV. Provider business mailing address

335 N HIGHLAND AVE
PRESTONSBURG KY
41653-7838
US

V. Phone/Fax

Practice location:
  • Phone: 606-548-3878
  • Fax:
Mailing address:
  • Phone: 606-548-3878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number283451
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: