Provider Demographics
NPI:1942978572
Name:ILLUME WELLNESS GROUP
Entity Type:Organization
Organization Name:ILLUME WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MERCHANT
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:269-503-1804
Mailing Address - Street 1:971 S CENTERVILLE RD # 145
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2502
Mailing Address - Country:US
Mailing Address - Phone:269-503-1804
Mailing Address - Fax:
Practice Address - Street 1:1904 E CHICAGO RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8522
Practice Address - Country:US
Practice Address - Phone:269-503-1804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty