Healthcare Provider Details

I. General information

NPI: 1295060788
Provider Name (Legal Business Name): LIGHT HOUSE FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 W DARROW ST
PHOENIX AZ
85041-6010
US

IV. Provider business mailing address

3910 W DARROW ST
PHOENIX AZ
85041-6010
US

V. Phone/Fax

Practice location:
  • Phone: 602-237-4066
  • Fax: 602-237-4066
Mailing address:
  • Phone: 602-237-4066
  • Fax: 602-237-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberBH3417
License Number StateAZ

VIII. Authorized Official

Name: MS. CLAUDETTE WALKER-SIMON
Title or Position: OWNER
Credential:
Phone: 602-237-4066