Healthcare Provider Details

I. General information

NPI: 1427573351
Provider Name (Legal Business Name): LIGHTHOUSE ABA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 08/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 WALKING HORSE CT
WILMINGTON NC
28411-7438
US

IV. Provider business mailing address

PO BOX 11403
WILMINGTON NC
28404-1403
US

V. Phone/Fax

Practice location:
  • Phone: 910-228-3091
  • Fax:
Mailing address:
  • Phone: 910-228-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-13055
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4583
License Number StateNC

VIII. Authorized Official

Name: MRS. KRISTIN LEIGH MUMPOWER
Title or Position: FOUNDER & BEHAVIOR ANALYST
Credential: LPA, BCBA
Phone: 910-228-3091