Healthcare Provider Details

I. General information

NPI: 1023936515
Provider Name (Legal Business Name): LUMINESCENCE THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 W FARWELL AVE APT 2N
CHICAGO IL
60626-3633
US

IV. Provider business mailing address

1621 W FARWELL AVE APT 2N
CHICAGO IL
60626-3633
US

V. Phone/Fax

Practice location:
  • Phone: 773-217-8819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KEETON PHILLIPS
Title or Position: OWNER
Credential: LCSW
Phone: 812-204-3469