Provider Demographics
NPI:1538728209
Name:ILLUMINATING POSSIBILITIES THERAPEUTIC SERVICES
Entity type:Organization
Organization Name:ILLUMINATING POSSIBILITIES THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CHIEF CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDAK
Authorized Official - Suffix:
Authorized Official - Credentials:EDD SLP BCBA-D LBA
Authorized Official - Phone:201-284-9136
Mailing Address - Street 1:434 DUNELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:DUNELLEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-1236
Mailing Address - Country:US
Mailing Address - Phone:551-226-1112
Mailing Address - Fax:
Practice Address - Street 1:983 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-3601
Practice Address - Country:US
Practice Address - Phone:201-284-9136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1235376997OtherPRIVATE INSURANCE