Provider Demographics
NPI:1366134561
Name:LUMINOUS SELF PLLC
Entity type:Organization
Organization Name:LUMINOUS SELF PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:RHIANNON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:240-406-9339
Mailing Address - Street 1:119 SADER DR STE 4
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-3915
Mailing Address - Country:US
Mailing Address - Phone:240-406-9339
Mailing Address - Fax:
Practice Address - Street 1:119 SADER DR STE 4
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-3915
Practice Address - Country:US
Practice Address - Phone:240-406-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty