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General NPI Number Information
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NPI Number | 1295383685
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Entity Type | Organization
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Legal Business Name | LILLISAGE THERAPY COLLECTIVE
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Dates
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Enumeration Date | 08/28/2019
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Last Update Date | 03/21/2025
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Provider Practice Location Address
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Address Line | 1901 PARKVIEW AVE STE 1
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City | KALAMAZOO
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State | MI
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Zip | 49008-4806
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Country | US
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Telephone | 269-225-5148
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Fax |
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Provider Business Mailing Address
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Address Line | 1901 PARKVIEW AVE STE 1
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City | KALAMAZOO
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State | MI
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Zip | 49008-4806
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Country | US
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Telephone | 269-225-5148
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. KELSEY NIMMO
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Credential | MA, LPC, LLMFT
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Telephone | 269-225-5148
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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