Healthcare Provider Details

I. General information

NPI: 1912216219
Provider Name (Legal Business Name): LIGHTHOUSE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 09/02/2025
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 E WEBSTER PL SUITE 203
MILWAUKEE WI
53211-4256
US

IV. Provider business mailing address

2524 E WEBSTER PL STE 203
MILWAUKEE WI
53211-4257
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-9200
  • Fax: 414-964-4816
Mailing address:
  • Phone: 414-964-9200
  • Fax: 414-964-4816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: PAULA TUDOROF
Title or Position: OWNER/MANAGER
Credential:
Phone: 323-447-9507