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General NPI Number Information
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NPI Number | 1730459124
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Entity Type | Organization
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Legal Business Name | LILY BAY LLC
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Dates
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Enumeration Date | 01/03/2012
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Last Update Date | 01/03/2012
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Provider Practice Location Address
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Address Line | 15 WEISS AVE
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City | EASTON
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State | PA
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Zip | 18042
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Country | US
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Telephone | 610-250-7595
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Fax | 610-250-7595
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Provider Business Mailing Address
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Address Line | 15 WEISS AVE
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City | EASTON
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State | PA
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Zip | 18042
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Country | US
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Telephone | 610-250-7595
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Fax | 610-250-7595
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Authorized Official
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Title or Position | CEO
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Name | MR. WARREN AUSTIN
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Credential |
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Telephone | 610-250-7595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | PC004551
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License Number State | PA
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