Provider Demographics
NPI:1720840846
Name:ILLUMINATE MENTAL HEALTH PA
Entity Type:Organization
Organization Name:ILLUMINATE MENTAL HEALTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MEWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-222-3495
Mailing Address - Street 1:681 BOX BRANCH CIR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4379
Mailing Address - Country:US
Mailing Address - Phone:540-222-3495
Mailing Address - Fax:
Practice Address - Street 1:12627 SAN JOSE BLVD STE 301
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8639
Practice Address - Country:US
Practice Address - Phone:540-222-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)