MEDICARE: LILLY LITTLE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	05381	TX
2	1041C0700X	Clinical Social Worker	05381	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0060MR	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114955465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLY LITTLE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 972355
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79997-2355
Country	:	US
Telephone Number	:	915-449-1549
Fax Number	:	877-606-9254

Provider Business Practice Location Address
First Line	:	2150 TRAWOOD DR BLDG B
Second Line	:	SUITE 252
City	:	EL PASO
State	:	TX
Zip	:	79935-3322
Country	:	US
Telephone Number	:	915-449-1549
Fax Number	:	877-606-9254

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	05/29/2012

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