MEDICARE: ELISE LILLARD IPOCK M.S.

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1730357179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE LILLARD IPOCK M.S.

Provider Business Mailing Address
First Line	:	414 HARRISON ST
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-3516
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	414 HARRISON ST
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-3516
Country	:	US
Telephone Number	:	765-743-4639
Fax Number	:

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

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	02/19/2008

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