Provider Demographics
NPI:1699384495
Name:ILLUMINATION PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:ILLUMINATION PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:INFRANCO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-209-7564
Mailing Address - Street 1:375 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1663
Mailing Address - Country:US
Mailing Address - Phone:631-209-7564
Mailing Address - Fax:
Practice Address - Street 1:375 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1663
Practice Address - Country:US
Practice Address - Phone:631-209-7564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty