Healthcare Provider Details

I. General information

NPI: 1265863641
Provider Name (Legal Business Name): LIGHTRISE FAMILY CHRISTIAN COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 EXCHANGE DR 101B
CRYSTAL LAKE IL
60014-6230
US

IV. Provider business mailing address

265 EXCHANGE DR 101B
CRYSTAL LAKE IL
60014-6230
US

V. Phone/Fax

Practice location:
  • Phone: 224-286-4673
  • Fax:
Mailing address:
  • Phone: 224-286-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MADISON BERESFORD
Title or Position: PRESIDENT/LEAD PASTORAL COUNSELOR
Credential: M.A.
Phone: 224-286-4673