Healthcare Provider Details

I. General information

NPI: 1578989786
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S COMMERCE ST BLDG B
ARDMORE OK
73401-5519
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5636
  • Fax: 580-226-6727
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-223-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number100728830
License Number StateOK

VIII. Authorized Official

Name: DEANA THARP
Title or Position: DEPUTY EXECUTIVE DIRECTOR
Credential: LPC
Phone: 580-319-7305