Healthcare Provider Details

I. General information

NPI: 1215022041
Provider Name (Legal Business Name): THE COMMUNITY LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 ACADEMY RD NE STE 2-200
ALBUQUERQUE NM
87109-3380
US

IV. Provider business mailing address

7801 ACADEMY RD NE STE 2-200
ALBUQUERQUE NM
87109-3380
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-9391
  • Fax: 505-265-7860
Mailing address:
  • Phone: 505-273-6300
  • Fax: 505-265-7860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. PIERCE LEE FERRIEGEL
Title or Position: COO
Credential:
Phone: 505-273-6300