Provider Demographics
NPI:1720871494
Name:GLENN, LILLY N
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:N
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 JASPER AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1866
Mailing Address - Country:US
Mailing Address - Phone:715-817-6057
Mailing Address - Fax:
Practice Address - Street 1:900 W SHARON AVE
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1920
Practice Address - Country:US
Practice Address - Phone:906-482-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician