Healthcare Provider Details

I. General information

NPI: 1427319573
Provider Name (Legal Business Name): COACHELLA VALLEY LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78900 AVENUE 47 SUITE 105
LA QUINTA CA
92253-2070
US

IV. Provider business mailing address

PO BOX 355
INDIO CA
92202-0355
US

V. Phone/Fax

Practice location:
  • Phone: 760-625-0951
  • Fax: 760-564-5049
Mailing address:
  • Phone: 760-625-0951
  • Fax: 760-564-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-10337
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLEP3111
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLEP3111
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberLEP3111
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP3111
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ROSALES
Title or Position: CEO/EXECUTIVE CLINICAL DIRECTOR
Credential: BCBA
Phone: 760-625-0951