Healthcare Provider Details

I. General information

NPI: 1609673391
Provider Name (Legal Business Name): LAMPLIGHT THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 N 5TH ST
COTTAGE GROVE OR
97424-2005
US

IV. Provider business mailing address

73560 ABEENE LN
COTTAGE GROVE OR
97424-9201
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-8082
  • Fax: 866-931-2340
Mailing address:
  • Phone: 541-357-8082
  • Fax: 866-931-2340

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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTRA VICTORIA RENAULT
Title or Position: OWNER, THERAPIST
Credential: LCSW
Phone: 541-357-8082