Healthcare Provider Details

I. General information

NPI: 1295383685
Provider Name (Legal Business Name): LILLISAGE THERAPY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 PARKVIEW AVE STE 1
KALAMAZOO MI
49008-4806
US

IV. Provider business mailing address

1901 PARKVIEW AVE STE 1
KALAMAZOO MI
49008-4806
US

V. Phone/Fax

Practice location:
  • Phone: 269-225-5148
  • Fax:
Mailing address:
  • Phone: 269-225-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. KELSEY NIMMO
Title or Position: OWNER
Credential: MA, LPC, LLMFT
Phone: 269-225-5148