Provider Demographics
NPI:1740745934
Name:LUMINATE THERAPY GROUP OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:LUMINATE THERAPY GROUP OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-858-9900
Mailing Address - Street 1:7500 RIALTO BOULEVARD
Mailing Address - Street 2:BUILDING 1 SUITE 260
Mailing Address - City:AUSTIN TX
Mailing Address - State:TX
Mailing Address - Zip Code:78735
Mailing Address - Country:US
Mailing Address - Phone:512-858-9900
Mailing Address - Fax:512-858-9901
Practice Address - Street 1:580 SLAWIN COURT
Practice Address - Street 2:
Practice Address - City:MT. PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056
Practice Address - Country:US
Practice Address - Phone:224-612-8338
Practice Address - Fax:512-894-9901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUMINATE THERAPY GROUP OF ILLINOIS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty