Healthcare Provider Details

I. General information

NPI: 1023528916
Provider Name (Legal Business Name): MOUNTAIN LIGHT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1396 ROSELAWN AVE
THOUSAND OAKS CA
91362-2031
US

IV. Provider business mailing address

2060 E AVENIDA DE LOS ARBOLES # 275D
THOUSAND OAKS CA
91362-1361
US

V. Phone/Fax

Practice location:
  • Phone: 805-443-5859
  • Fax:
Mailing address:
  • Phone: 805-443-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP LICHTENBERGER
Title or Position: CEO
Credential: BCBA
Phone: 805-443-5859