Provider Demographics
NPI:1235317579
Name:LILLY, SUSAN QUINN (MSCCC/SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:QUINN
Last Name:LILLY
Suffix:
Gender:F
Credentials:MSCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26351-1216
Mailing Address - Country:US
Mailing Address - Phone:304-462-7386
Mailing Address - Fax:304-462-5103
Practice Address - Street 1:201 N COURT ST
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1216
Practice Address - Country:US
Practice Address - Phone:304-462-7386
Practice Address - Fax:304-462-5103
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0155220000Medicaid