Healthcare Provider Details

I. General information

NPI: 1730684879
Provider Name (Legal Business Name): REBECCA LILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 EDALBERT DR
CINCINNATI OH
45239-7695
US

IV. Provider business mailing address

5400 EDALBERT DR
CINCINNATI OH
45239-7695
US

V. Phone/Fax

Practice location:
  • Phone: 513-741-3100
  • Fax:
Mailing address:
  • Phone: 513-741-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0004393-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: