{
"Npi": {
"NPI": "1063236214",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ILLUMINATE GROUP LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 478",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FAIRHOPE",
"MailingAddressStateName": "AL",
"MailingAddressPostalCode": "36533-0478",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "251-517-5398",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1040 STANTON RD",
"SecondLinePracticeLocationAddress": "SUITE H",
"PracticeLocationAddressCityName": "DAPHNE",
"PracticeLocationAddressStateName": "AL",
"PracticeLocationAddressPostalCode": "36526",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "251-517-5398",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/14/2024",
"LastUpdateDate": "11/14/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CASOLARO",
"AuthorizedOfficialFirstName": "THOMAS",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "FOUNDER/CLINICAL DIRECTOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LICSW-S",
"AuthorizedOfficialTelephoneNumber": "251-517-5398",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QM0850X",
"TaxonomyName": "Adult Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0855X",
"TaxonomyName": "Adolescent and Children Mental Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM1300X",
"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}