Healthcare Provider Details

I. General information

NPI: 1639545965
Provider Name (Legal Business Name): LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 24TH AVE SW
NORMAN OK
73069-5106
US

IV. Provider business mailing address

510 24TH AVE SW
NORMAN OK
73069-5106
US

V. Phone/Fax

Practice location:
  • Phone: 405-329-7923
  • Fax: 405-329-8815
Mailing address:
  • Phone: 405-329-7923
  • Fax: 405-329-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5124
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1237
License Number StateOK

VIII. Authorized Official

Name: CALEY GREGG
Title or Position: LICENSED HEALTH SERVICE PSYCHOLOGIS
Credential: PHD
Phone: 405-641-5367