Healthcare Provider Details

I. General information

NPI: 1689832347
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5070
  • Fax:
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-319-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

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