Illuminate Psychotherapy PLLC

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

Legal business name

ILLUMINATE PSYCHOTHERAPY PLLC

Practice address

101 Jordan Dr
Chattanooga, TN 37421-6732

Phone

(423) 510-1999

NPI assigned

Aug 11, 2020

Last updated

Aug 11, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Judy Gilliam

Title

Administrative Expert

Phone

(423) 510-1999

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TN

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Pooja Khariwal

  • Clinical Psychologist
  • Chattanooga, TN
  • NPI 1063846822
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1597104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1597104000000",
    "number": "1417568890",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 JORDAN DR",
            "city": "CHATTANOOGA",
            "state": "TN",
            "postal_code": "374216732",
            "telephone_number": "423-510-1999"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 JORDAN DR",
            "city": "CHATTANOOGA",
            "state": "TN",
            "postal_code": "374216732",
            "telephone_number": "423-510-1999"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ILLUMINATE PSYCHOTHERAPY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-08-11",
        "last_updated": "2020-08-11",
        "certification_date": "2020-08-11",
        "status": "A",
        "authorized_official_last_name": "GILLIAM",
        "authorized_official_first_name": "JUDY",
        "authorized_official_title_or_position": "ADMINISTRATIVE EXPERT",
        "authorized_official_telephone_number": "423-510-1999",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.