Healthcare Provider Details

I. General information

NPI: 1508472648
Provider Name (Legal Business Name): ILLUME COUNSELING & PLAY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35008 EMERALD COAST PKWY STE 203
DESTIN FL
32541-4752
US

IV. Provider business mailing address

416 PRIMROSE CIR
DESTIN FL
32541-2232
US

V. Phone/Fax

Practice location:
  • Phone: 251-209-0680
  • Fax:
Mailing address:
  • Phone: 251-209-0680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELSEY LAINE BACKES
Title or Position: PRESIDENT
Credential:
Phone: 251-209-0216