Healthcare Provider Details

I. General information

NPI: 1548885726
Provider Name (Legal Business Name): ILLUMII
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 REYNOLDA VLG STE A
WINSTON SALEM NC
27106-5126
US

IV. Provider business mailing address

121 REYNOLDA VLG STE A
WINSTON SALEM NC
27106-5126
US

V. Phone/Fax

Practice location:
  • Phone: 336-893-9018
  • Fax: 833-748-0121
Mailing address:
  • Phone: 336-893-9018
  • Fax: 833-748-0121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTIN R BENNETT
Title or Position: DIRECTOR
Credential: PHD.
Phone: 336-893-9018