Organization
ILLUMINATE KETAMINE CENTER PLLC
Active
Other names
Illuminate Wellness Center
Organization subpart
No
Provider details
NPI number
Authorized official
SHELIA BEASLEY CRNA (CO-OWNER/ PRESIDENT)
(423) 765-0777
Entity
Organization
Contact information
Practice address
1936 BROOKSIDE DR STE E, KINGSPORT, TN 37660-4654
(423) 765-0777
Mailing address
1936 BROOKSIDE DR STE E, KINGSPORT, TN 37660-4654
(423) 765-0777
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
—
—
106H00000X
Marriage & Family Therapist
—
—
261QI0500X
Infusion Therapy Clinic/Center
—
—
367500000X
Certified Registered Nurse Anesthetist
Primary
—
—
Other
Enumeration date
04/22/2019
Last updated
03/03/2021
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