Provider Demographics
NPI:1477877223
Name:LILAC CENTER LLC
Entity Type:Organization
Organization Name:LILAC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TIBBITTS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:816-221-0305
Mailing Address - Street 1:2029 BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3405
Mailing Address - Country:US
Mailing Address - Phone:816-221-0305
Mailing Address - Fax:816-221-9121
Practice Address - Street 1:2029 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3405
Practice Address - Country:US
Practice Address - Phone:816-221-0305
Practice Address - Fax:816-221-9121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174524101YM0800X
261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201354450AMedicaid
MO830117171Medicaid