Provider Demographics
NPI:1053186247
Name:ILLUMINATE HEALING LLC
Entity type:Organization
Organization Name:ILLUMINATE HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINNEA
Authorized Official - Middle Name:
Authorized Official - Last Name:STENHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-272-1482
Mailing Address - Street 1:3439 SE HAWTHORNE BLVD # 1177
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5048
Mailing Address - Country:US
Mailing Address - Phone:503-272-1482
Mailing Address - Fax:503-427-9765
Practice Address - Street 1:2926 NE FLANDERS ST STE 3A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3259
Practice Address - Country:US
Practice Address - Phone:503-272-1482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500704520Medicaid