MEDICARE: LIGHTHOUSE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	103G00000X	Clinical Neuropsychologist
3	133V00000X	Registered Dietitian
4	2084P0800X	Psychiatry Physician
5	2084P0804X	Child & Adolescent Psychiatry Physician
6	101YM0800X	Mental Health Counselor
7	101YP2500X	Professional Counselor
8	103T00000X	Psychologist

General Provider Information

NPI Number	:	1912216219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE CLINIC

Provider Business Mailing Address
First Line	:	2524 E WEBSTER PL STE 203
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4257
Country	:	US
Telephone Number	:	414-964-9200
Fax Number	:	414-964-4816

Provider Business Practice Location Address
First Line	:	2524 E WEBSTER PL STE 203
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4257
Country	:	US
Telephone Number	:	414-964-9200
Fax Number	:	414-964-4816

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PAULA TUDOROF
Credential	:
Telephone Number	:	323-447-9507

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	06/01/2026

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Directions to “LIGHTHOUSE CLINIC ” Practice Location

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