Healthcare Provider Details

I. General information

NPI: 1457484875
Provider Name (Legal Business Name): LIGHTHOUSE FOR YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 SPENCER CT
WAKEFIELD RI
02879-2820
US

IV. Provider business mailing address

81 SPENCER CT
WAKEFIELD RI
02879-2820
US

V. Phone/Fax

Practice location:
  • Phone: 401-782-8940
  • Fax: 401-782-1145
Mailing address:
  • Phone: 401-782-8940
  • Fax: 401-782-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHERINE O'KULA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 401-782-8940