Provider Demographics
NPI:1700695442
Name:LILLIE, WYATT
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:LILLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JASPER
Other - Middle Name:
Other - Last Name:LILLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12303 E 104TH PL UNIT 105
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-2098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12303 E 104TH PL UNIT 105
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-2098
Practice Address - Country:US
Practice Address - Phone:720-617-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician