Healthcare Provider Details

I. General information

NPI: 1902602402
Provider Name (Legal Business Name): SHORE LIGHT BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25542 RHODA DR
MISSION VIEJO CA
92691-4669
US

IV. Provider business mailing address

2955 E 1ST AVE STE 200
DENVER CO
80206-5636
US

V. Phone/Fax

Practice location:
  • Phone: 888-486-6717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN VANHOOSER
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 949-750-2014