MEDICARE: MARY HELEN LILLICH PHD

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	103T00000X	Psychologist	1665057	WI

General Provider Information

NPI Number	:	1346312808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY HELEN LILLICH PHD

Provider Business Mailing Address
First Line	:	101 FALLS RD
Second Line	:	SUITE 404
City	:	GRAFTON
State	:	WI
Zip	:	53024-2612
Country	:	US
Telephone Number	:	262-375-8441
Fax Number	:	262-546-0005

Provider Business Practice Location Address
First Line	:	101 FALLS RD
Second Line	:	SUITE 404
City	:	GRAFTON
State	:	WI
Zip	:	53024-2612
Country	:	US
Telephone Number	:	262-375-8441
Fax Number	:	262-546-0005

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

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	01/30/2008

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