Provider Demographics
NPI:1295212355
Name:KESMA FLAME LILY LLC
Entity Type:Organization
Organization Name:KESMA FLAME LILY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETRONELLAH
Authorized Official - Middle Name:THOKO
Authorized Official - Last Name:THOMAS-SHANOBI
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:612-408-7733
Mailing Address - Street 1:20705 OTERO AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-9600
Mailing Address - Country:US
Mailing Address - Phone:612-408-7733
Mailing Address - Fax:763-292-5653
Practice Address - Street 1:2800 FREEWAY BLVD
Practice Address - Street 2:STE 204/7
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-5543
Practice Address - Country:US
Practice Address - Phone:612-408-7733
Practice Address - Fax:763-292-5653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-22
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0000000OtherBEHAVIORAL HEALTH
MN6744924000Medicaid