Healthcare Provider Details

I. General information

NPI: 1033597315
Provider Name (Legal Business Name): LIGHTHOUSE COUNSELING LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 STATE ST
SAINT JOSEPH MI
49085-1369
US

IV. Provider business mailing address

521 STATE ST
SAINT JOSEPH MI
49085-1369
US

V. Phone/Fax

Practice location:
  • Phone: 269-408-6031
  • Fax: 269-408-6031
Mailing address:
  • Phone: 269-408-6031
  • Fax: 269-408-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401014597
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401012473
License Number StateMI

VIII. Authorized Official

Name: MISS VINEESHA RATHNAM
Title or Position: PARTNER
Credential:
Phone: 269-408-6031