Healthcare Provider Details

I. General information

NPI: 1376360495
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W UNIVERSITY BLVD STE 100
DURANT OK
74701-2970
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-745-1188
  • Fax:
Mailing address:
  • Phone: 580-319-7305
  • Fax: 580-319-7328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEANA THARP
Title or Position: CHIEF CLINICAL COMPLIANCE OFFICER
Credential: LPC
Phone: 580-319-7305