Provider Demographics
NPI:1295383685
Name:LILLISAGE THERAPY COLLECTIVE
Entity Type:Organization
Organization Name:LILLISAGE THERAPY COLLECTIVE
Other - Org Name:KALAMAZOO THERAPY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIMMO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LLMFT
Authorized Official - Phone:269-225-5148
Mailing Address - Street 1:1901 PARKVIEW AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-4806
Mailing Address - Country:US
Mailing Address - Phone:269-225-5148
Mailing Address - Fax:
Practice Address - Street 1:1901 PARKVIEW AVE STE 1
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-4806
Practice Address - Country:US
Practice Address - Phone:269-225-5148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty