Healthcare Provider Details

I. General information

NPI: 1578393591
Provider Name (Legal Business Name): LILLYS PLACE CONSULTANT FIRM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 MARSHALL HALL RD
BRYANS ROAD MD
20616-3243
US

IV. Provider business mailing address

2708 MARSHALL HALL RD
BRYANS ROAD MD
20616-3243
US

V. Phone/Fax

Practice location:
  • Phone: 202-812-8674
  • Fax:
Mailing address:
  • Phone: 202-812-8674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. MELODY SMITH
Title or Position: MANAGER
Credential:
Phone: 202-812-8674