Healthcare Provider Details

I. General information

NPI: 1740672880
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
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

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

V. Phone/Fax

Practice location:
  • Phone: 580-924-7331
  • Fax: 580-924-7332
Mailing address:
  • Phone: 580-924-7330
  • Fax: 580-924-2739

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