Healthcare Provider Details

I. General information

NPI: 1083365639
Provider Name (Legal Business Name): LIGHTHOUSE PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11174 E 13 MILE RD
WARREN MI
48093-2559
US

IV. Provider business mailing address

11174 E 13 MILE RD
WARREN MI
48093-2559
US

V. Phone/Fax

Practice location:
  • Phone: 313-285-3978
  • Fax:
Mailing address:
  • Phone: 313-285-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALLYSON DOLL ANDREWS
Title or Position: CEO
Credential:
Phone: 313-285-3978