Provider Demographics
NPI:1235808221
Name:ILLUMINATE THERAPY LLC
Entity Type:Organization
Organization Name:ILLUMINATE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-490-7943
Mailing Address - Street 1:2 KLARIDES VILLAGE DR # 272
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2737
Mailing Address - Country:US
Mailing Address - Phone:203-490-7943
Mailing Address - Fax:
Practice Address - Street 1:2 KLARIDES VILLAGE DR # 272
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-2737
Practice Address - Country:US
Practice Address - Phone:203-490-7943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty