Healthcare Provider Details

I. General information

NPI: 1073128351
Provider Name (Legal Business Name): LILLY'S INTERNAL LIGHT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2020
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 COORS BYP NW STE EO1
ALBUQUERQUE NM
87114-4040
US

IV. Provider business mailing address

PO BOX 45281
RIO RANCHO NM
87174-5281
US

V. Phone/Fax

Practice location:
  • Phone: 505-918-0455
  • Fax:
Mailing address:
  • Phone: 505-677-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: FRANCINE HERNANDEZ
Title or Position: CO-OWNER
Credential: LCSW
Phone: 505-918-7412