Provider Demographics
NPI:1528569597
Name:ILLUMINATION COUNSELING & CONSULTATION SERVICES LLC
Entity Type:Organization
Organization Name:ILLUMINATION COUNSELING & CONSULTATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDER
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP
Authorized Official - Phone:308-765-2401
Mailing Address - Street 1:3539 S 40TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5615
Mailing Address - Country:US
Mailing Address - Phone:308-765-2401
Mailing Address - Fax:
Practice Address - Street 1:3539 S 40TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5615
Practice Address - Country:US
Practice Address - Phone:308-765-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1905101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE50504818202Medicaid