Healthcare Provider Details

I. General information

NPI: 1821564790
Provider Name (Legal Business Name): LIGHTHOUSE MENTAL WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 RIVERSIDE DR STE 260
PEMBROKE MA
02359-4947
US

IV. Provider business mailing address

28 RIVERSIDE DR STE 260
PEMBROKE MA
02359-4947
US

V. Phone/Fax

Practice location:
  • Phone: 781-472-7070
  • Fax: 781-472-7071
Mailing address:
  • Phone: 781-427-7070
  • Fax: 781-472-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRIAN BANKS
Title or Position: PSYCHIATRIC NP/OWNER
Credential: PMHNP-BC
Phone: 781-427-7070