Healthcare Provider Details

I. General information

NPI: 1700598489
Provider Name (Legal Business Name): LIGHT CENTER BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 N 19TH AVE # C1
PHOENIX AZ
85015-1631
US

IV. Provider business mailing address

6619 N 19TH AVE # C1
PHOENIX AZ
85015-1631
US

V. Phone/Fax

Practice location:
  • Phone: 520-445-5832
  • Fax:
Mailing address:
  • Phone: 520-445-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNE MARIE NTIRANYIBAGIRA
Title or Position: PARTNER
Credential:
Phone: 520-445-5832