Healthcare Provider Details

I. General information

NPI: 1871788349
Provider Name (Legal Business Name): LIGHTHOUSE CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N CIRCLE DR
COLORADO SPRINGS CO
80909-1184
US

IV. Provider business mailing address

2500 N CIRCLE DR
COLORADO SPRINGS CO
80909-1184
US

V. Phone/Fax

Practice location:
  • Phone: 719-636-3784
  • Fax: 719-630-3211
Mailing address:
  • Phone: 719-636-3784
  • Fax: 719-630-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1788
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2998
License Number StateCO

VIII. Authorized Official

Name: DR. BOB GANT
Title or Position: PRESIDENT
Credential: PHD
Phone: 719-636-3784