Healthcare Provider Details

I. General information

NPI: 1790389559
Provider Name (Legal Business Name): LILIAN IONA YABUT LCPC ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13426 WATERS EDGE WAY
GULFPORT MS
39503-6067
US

IV. Provider business mailing address

13426 WATERS EDGE WAY
GULFPORT MS
39503-6067
US

V. Phone/Fax

Practice location:
  • Phone: 406-223-1636
  • Fax:
Mailing address:
  • Phone: 406-223-1636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number45187
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: