Healthcare Provider Details

I. General information

NPI: 1366942781
Provider Name (Legal Business Name): MISS LATONYA LILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 10/18/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9530 PERRY HALL BLVD APT 202
NOTTINGHAM MD
21236-1337
US

IV. Provider business mailing address

306 N KENSINGTON AVE
LA GRANGE PARK IL
60526-1870
US

V. Phone/Fax

Practice location:
  • Phone: 443-725-6064
  • Fax:
Mailing address:
  • Phone: 312-914-0611
  • Fax: 312-919-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: