Healthcare Provider Details

I. General information

NPI: 1932716818
Provider Name (Legal Business Name): HALIE RENEE LILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

IV. Provider business mailing address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-2090
  • Fax:
Mailing address:
  • Phone: 304-872-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: