Provider Demographics
NPI:1609168145
Name:ILLUMINATA HEALING ARTS
Entity Type:Organization
Organization Name:ILLUMINATA HEALING ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOZNYSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-203-5177
Mailing Address - Street 1:230 BRIGGS PURCHASE
Mailing Address - Street 2:
Mailing Address - City:LOTHIAN
Mailing Address - State:MD
Mailing Address - Zip Code:20711
Mailing Address - Country:US
Mailing Address - Phone:443-203-5177
Mailing Address - Fax:410-257-2219
Practice Address - Street 1:230 BRIGGS PURCHASE
Practice Address - Street 2:
Practice Address - City:LOTHIAN
Practice Address - State:MD
Practice Address - Zip Code:20711
Practice Address - Country:US
Practice Address - Phone:443-203-5177
Practice Address - Fax:410-257-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty