Healthcare Provider Details

I. General information

NPI: 1457199614
Provider Name (Legal Business Name): IDALUZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1869 S CARISBROOK PL
AUSTELL GA
30168-5147
US

IV. Provider business mailing address

1869 S CARISBROOK PL
AUSTELL GA
30168-5147
US

V. Phone/Fax

Practice location:
  • Phone: 401-588-0121
  • Fax:
Mailing address:
  • Phone: 401-588-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: IOLANDA L DA LUZ
Title or Position: MENTAL HEALTH PROFESSIONAL
Credential: LPC, NCC, LPCA
Phone: 401-588-0121