Basic Information
| Provider Information | |||||||||
| NPI: | 1588922140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLEY | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | AMOS | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12414 MILLS ST | ||||||||
| Address2: | |||||||||
| City: | GROVELAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953219322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099626540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 TULLY RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953502946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095761750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | LMFT 19577 | CA | Y | Other Service Providers | Contractor |
No ID Information.