Healthcare Provider Details

I. General information

NPI: 1083436067
Provider Name (Legal Business Name): ILLUMINATE MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 E LONGVIEW DR LOWR LEVEL
APPLETON WI
54911-2130
US

IV. Provider business mailing address

626 E LONGVIEW DR LOWR LEVEL
APPLETON WI
54911-2130
US

V. Phone/Fax

Practice location:
  • Phone: 920-215-2260
  • Fax:
Mailing address:
  • Phone: 920-215-2260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DEDRA M BUTEYN
Title or Position: OWNER
Credential: LPC
Phone: 920-215-2260