Healthcare Provider Details

I. General information

NPI: 1972659910
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N 1ST ST
MADILL OK
73446-1406
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-798-0111
  • Fax:
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-223-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: LPC
Credential:
Phone: 580-319-7305