MEDICARE: ILLUMINATA HEALING ARTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	11090	MD

General Provider Information

NPI Number	:	1609168145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLUMINATA HEALING ARTS

Provider Business Mailing Address
First Line	:	230 BRIGGS PURCHASE
Second Line	:
City	:	LOTHIAN
State	:	MD
Zip	:	20711
Country	:	US
Telephone Number	:	443-203-5177
Fax Number	:	410-257-2219

Provider Business Practice Location Address
First Line	:	230 BRIGGS PURCHASE
Second Line	:
City	:	LOTHIAN
State	:	MD
Zip	:	20711
Country	:	US
Telephone Number	:	443-203-5177
Fax Number	:	410-257-2219

Authorized Official
Title or Position	:	OWNER
Name	:	MARY WOZNYSMITH
Credential	:	LCSW-C
Telephone Number	:	443-203-5177

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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