Provider Demographics
NPI:1902655178
Name:LUMINOUS PATH THERAPY
Entity type:Organization
Organization Name:LUMINOUS PATH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-245-9455
Mailing Address - Street 1:8415 SHIRLEY CT APT 11
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4764
Mailing Address - Country:US
Mailing Address - Phone:269-245-9455
Mailing Address - Fax:
Practice Address - Street 1:8415 SHIRLEY CT APT 11
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4764
Practice Address - Country:US
Practice Address - Phone:269-245-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-18
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)