Healthcare Provider Details

I. General information

NPI: 1972390912
Provider Name (Legal Business Name): LILY FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OLD GREAT NECK RD STE 203
VIRGINIA BEACH VA
23454-3358
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 571-934-3936
  • Fax: 617-807-0958
Mailing address:
  • Phone: 855-284-7483
  • Fax: 617-807-0958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0704014164
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: