Healthcare Provider Details

I. General information

NPI: 1215535117
Provider Name (Legal Business Name): ALEXIS NICOLE TILLERY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30150 TELEGRAPH RD STE 245
BINGHAM FARMS MI
48025-4521
US

IV. Provider business mailing address

30451 MARIMOOR ST
BEVERLY HILLS MI
48025-5041
US

V. Phone/Fax

Practice location:
  • Phone: 248-804-1595
  • Fax:
Mailing address:
  • Phone: 248-804-1595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851106976
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115423
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801115423
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: