Healthcare Provider Details

I. General information

NPI: 1740745934
Provider Name (Legal Business Name): LUMINATE THERAPY GROUP OF ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 SLAWIN COURT
MT. PROSPECT IL
60056
US

IV. Provider business mailing address

7500 RIALTO BOULEVARD BUILDING 1 SUITE 260
AUSTIN TX TX
78735
US

V. Phone/Fax

Practice location:
  • Phone: 224-612-8338
  • Fax: 512-894-9901
Mailing address:
  • Phone: 512-858-9900
  • Fax: 512-858-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TODD BOCK
Title or Position: PRESIDENT
Credential:
Phone: 512-858-9900