=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720840846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATE MENTAL HEALTH PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2024
-----------------------------------------------------
Last Update Date | 01/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12627 SAN JOSE BLVD STE 301
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-222-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 681 BOX BRANCH CIR
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-4379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-222-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT/OFFICER
-----------------------------------------------------
Name | MR. MATTHEW MEWHORTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-222-3495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------