Healthcare Provider Details

I. General information

NPI: 1013657238
Provider Name (Legal Business Name): LIGHTHOUSE KIDS HIXSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/06/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 NORTHPOINT BOULEVARD SUITE 140
HIXSON TN
37343
US

IV. Provider business mailing address

4427 HIGHLANDER DR
DALLAS TX
75287-6844
US

V. Phone/Fax

Practice location:
  • Phone: 502-974-5239
  • Fax:
Mailing address:
  • Phone: 502-974-5239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: JEFF WEST
Title or Position: CEO
Credential:
Phone: 502-974-5239