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General NPI Number Information
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NPI Number | 1578424446
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Entity Type | Organization
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Legal Business Name | ILLUMA BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 11/20/2025
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Last Update Date | 11/20/2025
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Provider Practice Location Address
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Address Line | 267 COUNTY ROAD 558
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City | TILLATOBA
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State | MS
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Zip | 38961-3101
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Country | US
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Telephone | 719-286-0774
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Fax |
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Provider Business Mailing Address
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Address Line | 3609 AUSTIN BLUFFS PKWY STE 31
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-6658
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | COFOUNDER
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Name | NICOLE PARKS
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Credential | BCBA, IBA, LBA
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Telephone | 704-614-7228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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