Healthcare Provider Details

I. General information

NPI: 1285449611
Provider Name (Legal Business Name): ILLUM THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N TRYON ST STE 1600
CHARLOTTE NC
28202-0213
US

IV. Provider business mailing address

525 N TRYON ST STE 1600
CHARLOTTE NC
28202-0213
US

V. Phone/Fax

Practice location:
  • Phone: 917-471-1484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DOV SMILOWITZ
Title or Position: OWNER
Credential:
Phone: 917-471-1484