Healthcare Provider Details

I. General information

NPI: 1104129287
Provider Name (Legal Business Name): LIGHTHOUSE COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 E OGDEN AVE SUITE 11
HINSDALE IL
60521-3648
US

IV. Provider business mailing address

244 E OGDEN AVE SUITE 11
HINSDALE IL
60521-3648
US

V. Phone/Fax

Practice location:
  • Phone: 630-325-4770
  • Fax:
Mailing address:
  • Phone: 630-325-4770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071004301
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166000403
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID PRESTON MACKINNON
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 630-325-4770