Healthcare Provider Details

I. General information

NPI: 1023838265
Provider Name (Legal Business Name): LACTATION LIGHTHOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W 11 MILE RD
MADISON HEIGHTS MI
48071-3103
US

IV. Provider business mailing address

905 W 11 MILE RD
MADISON HEIGHTS MI
48071-3103
US

V. Phone/Fax

Practice location:
  • Phone: 734-224-5471
  • Fax:
Mailing address:
  • Phone: 734-224-5471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA JOHNSON
Title or Position: OWNER/IBCLC
Credential: BSPH, IBCLC
Phone: 734-224-5471