Healthcare Provider Details

I. General information

NPI: 1104719525
Provider Name (Legal Business Name): ILLUMINATION THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SERPENTINE CT
SILVER SPRING MD
20904-5336
US

IV. Provider business mailing address

9 SERPENTINE CT
SILVER SPRING MD
20904-5336
US

V. Phone/Fax

Practice location:
  • Phone: 202-770-5759
  • Fax:
Mailing address:
  • Phone: 202-770-5759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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

VIII. Authorized Official

Name: AMY ZIMMERMAN
Title or Position: THERAPIST
Credential: LGMFT, LGPC, MT-BC
Phone: 202-656-6746