Provider Demographics
NPI:1972215853
Name:LILAC DRAGONFLY THERAPY
Entity type:Organization
Organization Name:LILAC DRAGONFLY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAITTLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-800-0204
Mailing Address - Street 1:506 RHONDA DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 RHONDA DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3346
Practice Address - Country:US
Practice Address - Phone:708-505-6747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty