Provider Demographics
NPI:1215535117
Name:TILLERY, ALEXIS NICOLE (LLMSW)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:TILLERY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30451 MARIMOOR ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5041
Mailing Address - Country:US
Mailing Address - Phone:248-804-1595
Mailing Address - Fax:
Practice Address - Street 1:30000 HIVELEY ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1089
Practice Address - Country:US
Practice Address - Phone:173-472-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011069761041C0700X
MI68511069761041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical