Provider Demographics
NPI:1699599282
Name:ILLUME MENTAL HEALTH GROUP
Entity type:Organization
Organization Name:ILLUME MENTAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADESEWA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADELEKUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-300-4673
Mailing Address - Street 1:1249 S GRAND AVE APT 615
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4556
Mailing Address - Country:US
Mailing Address - Phone:704-214-1102
Mailing Address - Fax:
Practice Address - Street 1:210 S ORANGE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1705
Practice Address - Country:US
Practice Address - Phone:323-300-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty