Healthcare Provider Details

I. General information

NPI: 1457926560
Provider Name (Legal Business Name): ILLUMINATE ABA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 A EAST 12TH STREET
BROOKLYN NY
11235
US

IV. Provider business mailing address

2733A E 12TH ST # C2
BROOKLYN NY
11235-4601
US

V. Phone/Fax

Practice location:
  • Phone: 334-558-6228
  • Fax:
Mailing address:
  • Phone: 248-846-8700
  • Fax: 248-846-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VICKIE DRAZIN
Title or Position: OWNER
Credential:
Phone: 212-235-1231