Healthcare Provider Details

I. General information

NPI: 1285013888
Provider Name (Legal Business Name): MARY KATHERINE LILLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SCARBRO ROAD
SCARBRO WV
25917
US

IV. Provider business mailing address

P O BOX 337 908 SCARBRO ROAD
SCARBRO WV
25917
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-2905
  • Fax: 304-465-5486
Mailing address:
  • Phone: 304-574-2905
  • Fax: 304-465-1518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00940388
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111436
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: