Healthcare Provider Details

I. General information

NPI: 1902723323
Provider Name (Legal Business Name): BRIAN LILLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1306 BOSSLER LN
O FALLON IL
62269-7128
US

V. Phone/Fax

Practice location:
  • Phone: 314-728-3321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: