Healthcare Provider Details

I. General information

NPI: 1578628392
Provider Name (Legal Business Name): LIGHT PSYCHIATRIC SERVICES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13113 EASTPOINT PARK BLVD SUITE D
LOUISVILLE KY
40223-4191
US

IV. Provider business mailing address

13113 EASTPOINT PARK BLVD SUITE D
LOUISVILLE KY
40223-4191
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-5437
  • Fax: 502-244-5003
Mailing address:
  • Phone: 502-244-5437
  • Fax: 502-244-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number36355
License Number StateKY

VIII. Authorized Official

Name: DR. MICHAEL JOHN LIGHT
Title or Position: CEO
Credential: MD
Phone: 502-244-5437