Healthcare Provider Details

I. General information

NPI: 1811140007
Provider Name (Legal Business Name): CALLY MARY LILLEY PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 BLOSSOM ST R101
BOSTON MA
02114-3104
US

IV. Provider business mailing address

16 BLOSSOM ST R101
BOSTON MA
02114-3104
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-6409
  • Fax: 617-248-0070
Mailing address:
  • Phone: 617-643-6409
  • Fax: 617-248-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number274284
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: