Provider Demographics
NPI:1285219576
Name:ILLUME PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:ILLUME PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THIEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-206-0282
Mailing Address - Street 1:41 WATCHUNG PLZ # 176
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4117
Mailing Address - Country:US
Mailing Address - Phone:973-206-0282
Mailing Address - Fax:
Practice Address - Street 1:440 FRANKLIN ST STE 200
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4379
Practice Address - Country:US
Practice Address - Phone:973-206-0282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty