Healthcare Provider Details

I. General information

NPI: 1548622723
Provider Name (Legal Business Name): LIGHTHOUSE RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2934 HANOVER DR
LIMA OH
45805-2926
US

IV. Provider business mailing address

825 S CABLE RD STE C
LIMA OH
45805-3467
US

V. Phone/Fax

Practice location:
  • Phone: 419-303-1311
  • Fax: 419-463-9255
Mailing address:
  • Phone: 419-303-1311
  • Fax: 419-463-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15423
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CYNTHIA HITES
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP-BC
Phone: 419-303-1311