Healthcare Provider Details

I. General information

NPI: 1134875727
Provider Name (Legal Business Name): LIGHTHOUSE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 E MAIN ST STE 106
MESA AZ
85207-8325
US

IV. Provider business mailing address

7303 E MAIN ST STE 106
MESA AZ
85207-8325
US

V. Phone/Fax

Practice location:
  • Phone: 480-332-0385
  • Fax:
Mailing address:
  • Phone: 480-332-0385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA EVANS
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-526-0302