Healthcare Provider Details

I. General information

NPI: 1063236214
Provider Name (Legal Business Name): ILLUMINATE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 STANTON RD SUITE H
DAPHNE AL
36526
US

IV. Provider business mailing address

PO BOX 478
FAIRHOPE AL
36533-0478
US

V. Phone/Fax

Practice location:
  • Phone: 251-517-5398
  • Fax:
Mailing address:
  • Phone: 251-517-5398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: THOMAS CASOLARO
Title or Position: FOUNDER/CLINICAL DIRECTOR
Credential: LICSW-S
Phone: 251-517-5398