Provider Demographics
NPI:1508472648
Name:ILLUME COUNSELING & PLAY THERAPY
Entity Type:Organization
Organization Name:ILLUME COUNSELING & PLAY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:LAINE
Authorized Official - Last Name:BACKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-209-0216
Mailing Address - Street 1:416 PRIMROSE CIR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2232
Mailing Address - Country:US
Mailing Address - Phone:251-209-0680
Mailing Address - Fax:
Practice Address - Street 1:35008 EMERALD COAST PKWY STE 203
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4752
Practice Address - Country:US
Practice Address - Phone:251-209-0680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-22
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty