Healthcare Provider Details

I. General information

NPI: 1053389841
Provider Name (Legal Business Name): LIGHTHOUSE YOUTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 TONG HOLLOW RD
BAINBRIDGE OH
45612-9421
US

IV. Provider business mailing address

401 E MCMILLAN ST
CINCINNATI OH
45206-1922
US

V. Phone/Fax

Practice location:
  • Phone: 740-634-3094
  • Fax: 740-634-3047
Mailing address:
  • Phone: 513-487-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOH

VIII. Authorized Official

Name: THUY KOLIK
Title or Position: VICE PRESIDENT, CFO & CAO
Credential:
Phone: 513-487-7106