Healthcare Provider Details

I. General information

NPI: 1649870346
Provider Name (Legal Business Name): ERIN M LILLY LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 02/04/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3321B CANDELARIA RD NE STE 406
ALBUQUERQUE NM
87107-1908
US

IV. Provider business mailing address

PO BOX 2455
TIJERAS NM
87059-2455
US

V. Phone/Fax

Practice location:
  • Phone: 575-386-7744
  • Fax:
Mailing address:
  • Phone: 575-386-7744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARI-ANNE CHANEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-554-3435