=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689569154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMA THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2025
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20731 HOLYOKE AVE STE 232
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-9825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-294-6850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20731 HOLYOKE AVE STE 232
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-9825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED AGENT
-----------------------------------------------------
Name | MRS. AYAAN AHMED ALI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-294-6850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------