Provider Demographics
NPI:1952070252
Name:ILLUME PSYCHOLOGY INCORPORATED
Entity Type:Organization
Organization Name:ILLUME PSYCHOLOGY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASKA-RUEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-216-1612
Mailing Address - Street 1:245 KENTUCKY STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-216-1612
Mailing Address - Fax:
Practice Address - Street 1:245 KENTUCKY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-216-1612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty