Healthcare Provider Details

I. General information

NPI: 1740196005
Provider Name (Legal Business Name): ILLUMINATE HORIZONS THERAPEUTIC STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 N 10TH ST STE 2
LINCOLN NE
68508-1125
US

IV. Provider business mailing address

9130 PEREGRINE RD
LINCOLN NE
68505-2693
US

V. Phone/Fax

Practice location:
  • Phone: 402-805-8360
  • Fax:
Mailing address:
  • Phone: 402-805-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JILLIAN MILES
Title or Position: PRESIDENT
Credential: LIMHP
Phone: 402-805-8360