Provider Demographics
NPI:1013566454
Name:ILLUMINATION COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:ILLUMINATION COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NCC
Authorized Official - Phone:484-402-4727
Mailing Address - Street 1:5 GREAT VALLEY PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1426
Mailing Address - Country:US
Mailing Address - Phone:484-402-4727
Mailing Address - Fax:
Practice Address - Street 1:5 GREAT VALLEY PKWY STE 210
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1426
Practice Address - Country:US
Practice Address - Phone:484-402-4727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty