Provider Demographics
NPI:1013557644
Name:ILLUMINATION PSYCHOTHERAPY, PLLC
Entity Type:Organization
Organization Name:ILLUMINATION PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-318-7304
Mailing Address - Street 1:7300 N CICERO AVE STE 102A
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1641
Mailing Address - Country:US
Mailing Address - Phone:773-318-7304
Mailing Address - Fax:
Practice Address - Street 1:7300 N CICERO AVE STE 102A
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1641
Practice Address - Country:US
Practice Address - Phone:773-318-7304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-11
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty