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General NPI Number Information
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NPI Number | 1659078640
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Entity Type | Organization
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Legal Business Name | ILLUMINATE PEDIATRIC THERAPIES LLC
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Dates
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Enumeration Date | 02/10/2023
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Last Update Date | 10/03/2023
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Provider Practice Location Address
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Address Line | 3806 CLAREMONT ST
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City | BALTIMORE
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State | MD
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Zip | 21224-2510
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Country | US
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Telephone | 845-242-6369
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Fax |
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Provider Business Mailing Address
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Address Line | 3717 BOSTON ST # 344
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City | BALTIMORE
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State | MD
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Zip | 21224-5752
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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/SPEECH-LANGUAGE PATHOLOGIST
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Name | BRIANA CLAIRE CABIBBO GILLIAMS
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Credential | M.S., CCC-SLP
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Telephone | 845-242-6369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number |
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License Number State |
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