Healthcare Provider Details

I. General information

NPI: 1912460106
Provider Name (Legal Business Name): LILLY MISTOPOULOS LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LILLY TEACHOUT

II. Dates (important events)

Enumeration Date: 04/13/2019
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 BROWNS LAKE RD
JACKSON MI
49201-8379
US

IV. Provider business mailing address

6700 BROWNS LAKE RD
JACKSON MI
49201-8379
US

V. Phone/Fax

Practice location:
  • Phone: 517-768-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6851118260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: