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General NPI Number Information
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NPI Number | 1609376987
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Entity Type | Organization
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Legal Business Name | ILLUMINATION PSYCHOTHERAPY SERVICES, LLC.
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Dates
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Enumeration Date | 02/13/2018
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Last Update Date | 01/31/2025
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Provider Practice Location Address
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Address Line | 4 WYNDHAM RD
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City | LAKEVILLE
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State | MA
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Zip | 02347-2264
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Country | US
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Telephone | 508-317-4927
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 915
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City | LAKEVILLE
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State | MA
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Zip | 02347-0915
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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 | OWNER
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Name | KATHRYN FERNANDES
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Credential | LMHC
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Telephone | 508-317-4927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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