1902775257 NPI number — LILY OF THE VALLEY SUPPORT ACADEMY LLC

Table of content: GRACE NAGALES GRACE NAGALES, LCSW (NPI 1063795557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902775257 NPI number — LILY OF THE VALLEY SUPPORT ACADEMY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LILY OF THE VALLEY SUPPORT ACADEMY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902775257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14302 S LA SALLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60827-2743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-757-3101
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14302 S LA SALLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60827-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-757-3101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2025

Additional Information

Authorized Official

Authorized Official Last Name:
HINES
Authorized Official First Name:
DIAMOND
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
773-757-3101

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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