=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003232547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE FAMILY COUNSELING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2014
-----------------------------------------------------
Last Update Date | 03/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 N. HARBOR BLVD. SUITE 908
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-285-8802
-----------------------------------------------------
Fax | 949-679-8929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3742 CARMEL AVE.
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-285-8802
-----------------------------------------------------
Fax | 949-679-8929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. LINDA MARIA BRAWLEY
-----------------------------------------------------
Credential | LMFT (MFC 36541)
-----------------------------------------------------
Telephone | 949-285-8802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC36541
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------