Provider Demographics
NPI:1457199614
Name:IDALUZ LLC
Entity type:Organization
Organization Name:IDALUZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:IOLANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DA LUZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC, LPCA
Authorized Official - Phone:401-588-0121
Mailing Address - Street 1:1869 S CARISBROOK PL
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-5147
Mailing Address - Country:US
Mailing Address - Phone:401-588-0121
Mailing Address - Fax:
Practice Address - Street 1:1869 S CARISBROOK PL
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-5147
Practice Address - Country:US
Practice Address - Phone:401-588-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty