Healthcare Provider Details

I. General information

NPI: 1629989785
Provider Name (Legal Business Name): LILAC BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SANBORN ST
FITCHBURG MA
01420-3756
US

IV. Provider business mailing address

105 SANBORN ST
FITCHBURG MA
01420-3756
US

V. Phone/Fax

Practice location:
  • Phone: 508-479-2969
  • Fax: 978-506-1759
Mailing address:
  • Phone: 508-479-2969
  • Fax: 978-506-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTA MADRID
Title or Position: PMHNP
Credential: PMHNP-BC
Phone: 508-479-2969