Healthcare Provider Details

I. General information

NPI: 1275406316
Provider Name (Legal Business Name): LIGHTHOUSE LANE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10409 MONTGOMERY PKWY NE STE 203K
ALBUQUERQUE NM
87111-3852
US

IV. Provider business mailing address

10409 MONTGOMERY PKWY NE STE 203K
ALBUQUERQUE NM
87111-3852
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-6333
  • Fax:
Mailing address:
  • Phone: 505-226-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JESSICA RIPES
Title or Position: OWNER
Credential: LCSW
Phone: 702-205-8826