Healthcare Provider Details

I. General information

NPI: 1982952545
Provider Name (Legal Business Name): LIGHTHOUSE BEHAVIORAL HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8310 MIDLOTHIAN TPKE
NORTH CHESTERFIELD VA
23235-5163
US

IV. Provider business mailing address

8310 MIDLOTHIAN TPKE
NORTH CHESTERFIELD VA
23235-5163
US

V. Phone/Fax

Practice location:
  • Phone: 804-447-6382
  • Fax: 804-447-6383
Mailing address:
  • Phone: 804-447-6382
  • Fax: 804-447-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ROBYN LOWRY JENNINGS
Title or Position: CEO
Credential:
Phone: 804-447-6382