=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467261255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATION COUNSELING AND CONSULTING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2025
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 WADSWORTH RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-9503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-591-8196
-----------------------------------------------------
Fax | 330-753-7353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 WADSWORTH RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-9503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-591-8196
-----------------------------------------------------
Fax | 330-753-7353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CYNTHIA MCQUOWN
-----------------------------------------------------
Credential | LPCC-S
-----------------------------------------------------
Telephone | 330-591-8196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------