Provider Demographics
NPI:1245093590
Name:ILLUMINATION PSYCHOTHERAPY, PLLC
Entity type:Organization
Organization Name:ILLUMINATION PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-318-7304
Mailing Address - Street 1:1715 ABBOTT AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4107
Mailing Address - Country:US
Mailing Address - Phone:773-318-7304
Mailing Address - Fax:
Practice Address - Street 1:450 S MAPLE RD STE 858
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3835
Practice Address - Country:US
Practice Address - Phone:773-318-7304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)