Healthcare Provider Details

I. General information

NPI: 1699135566
Provider Name (Legal Business Name): LIGHTHOUSE INTEGRATIVE COUNSELING SERVICES LCSW MARRIAGE AND FAMILY TH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 MAIN ST STE 203A
PORT JEFFERSON NY
11777-1686
US

IV. Provider business mailing address

414 MAIN ST STE 203A
PORT JEFFERSON NY
11777-1686
US

V. Phone/Fax

Practice location:
  • Phone: 631-478-3292
  • Fax: 631-476-1302
Mailing address:
  • Phone: 631-478-3292
  • Fax: 631-476-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number073603
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000230
License Number StateNY

VIII. Authorized Official

Name: MICHELLE D CONELLI
Title or Position: FOUNDER/DIRECTOR
Credential: LCSW, LMFT
Phone: 631-478-3292