=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215104542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. JULIE A LILLIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 08/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1375 GATEWAY BLVD STE 32
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-8304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-307-3703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 MANATEE BAY DR
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-2821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-307-3703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH14558
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------