Provider Demographics
NPI:1639789019
Name:ILLUME NORTH, LLC
Entity Type:Organization
Organization Name:ILLUME NORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VACCARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:218-302-4678
Mailing Address - Street 1:324 W SUPERIOR ST # 630
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1701
Mailing Address - Country:US
Mailing Address - Phone:218-380-7119
Mailing Address - Fax:651-925-0039
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:630 MEDICAL ARTS
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1701
Practice Address - Country:US
Practice Address - Phone:218-380-7119
Practice Address - Fax:651-925-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-31
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty