Healthcare Provider Details

I. General information

NPI: 1871130807
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL HEALTH SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E MAIN ST
COLUMBUS OH
43213-2950
US

IV. Provider business mailing address

4000 E MAIN ST
COLUMBUS OH
43213-2950
US

V. Phone/Fax

Practice location:
  • Phone: 614-334-6903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN DEAN
Title or Position: ADMIN
Credential:
Phone: 614-762-5206