Healthcare Provider Details

I. General information

NPI: 1043786882
Provider Name (Legal Business Name): LIGHTHOUSE FAMILY CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 9TH ST SW STE 1610
CANTON OH
44707-4714
US

IV. Provider business mailing address

6505 ROCKSIDE RD STE 105
INDEPENDENCE OH
44131-2386
US

V. Phone/Fax

Practice location:
  • Phone: 330-305-2753
  • Fax: 330-639-1712
Mailing address:
  • Phone: 330-697-7212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. AIMEE THOMAS
Title or Position: OWNER
Credential: PH.D.
Phone: 330-305-2753