Healthcare Provider Details

I. General information

NPI: 1023912250
Provider Name (Legal Business Name): LUMINA CLINICAL & CONSULTING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 BOONESBOROUGH RD
DEEP WATER WV
25057
US

IV. Provider business mailing address

PO BOX 83
DEEP WATER WV
25057-0083
US

V. Phone/Fax

Practice location:
  • Phone: 704-351-7932
  • Fax:
Mailing address:
  • Phone: 704-351-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: BOBBI DYER
Title or Position: MANAGING MEMBER
Credential:
Phone: 704-351-7932