Healthcare Provider Details

I. General information

NPI: 1275019861
Provider Name (Legal Business Name): LIGHTHOUSE THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 GARDEN ISLE CT
ORLANDO FL
32824-6218
US

IV. Provider business mailing address

1225 GARDEN ISLE CT
ORLANDO FL
32824-6218
US

V. Phone/Fax

Practice location:
  • Phone: 407-990-2847
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberSI2530
License Number StateFL

VIII. Authorized Official

Name: MS. INGRID ACOSTA
Title or Position: SLPA
Credential: SLPA
Phone: 407-990-2847