Basic Information
| Provider Information | |||||||||
| NPI: | 1275122442 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLUMINATED PATHWAY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2942 N 24TH ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026413006 | ||||||||
| FaxNumber: | 6026413151 | ||||||||
| Practice Location | |||||||||
| Address1: | 9920 W CAMELBACK RD UNIT 2026 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850375056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532080756 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2021 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6026413006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174200000X | N | Other Service Providers | Meals | 177F00000X | N | Other Service Providers | Lodging | 251B00000X | N | Agencies | Case Management | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251K00000X | N | Agencies | Public Health or Welfare | 253J00000X | N | Agencies | Foster Care Agency | 253Z00000X | N | Agencies | In Home Supportive Care | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.