Provider Demographics
NPI:1336910694
Name:INNER LIGHT THERAPY LLC
Entity Type:Organization
Organization Name:INNER LIGHT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MCKINZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTELKOW
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-908-0245
Mailing Address - Street 1:4345 TRACY TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9007
Mailing Address - Country:US
Mailing Address - Phone:269-908-0245
Mailing Address - Fax:
Practice Address - Street 1:4345 TRACY TRAIL CT
Practice Address - Street 2:
Practice Address - City:DORR
Practice Address - State:MI
Practice Address - Zip Code:49323-9007
Practice Address - Country:US
Practice Address - Phone:269-908-0245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)