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General NPI Number Information
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NPI Number | 1063031011
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE HOLISTIC WELLNESS
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Dates
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Enumeration Date | 04/09/2020
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Last Update Date | 04/09/2020
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Provider Practice Location Address
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Address Line | 1145 ZONOLITE RD NE STE 10
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City | ATLANTA
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State | GA
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Zip | 30306-2017
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Country | US
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Telephone | 678-984-9265
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Fax |
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Provider Business Mailing Address
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Address Line | 1145 ZONOLITE RD NE STE 10
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City | ATLANTA
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State | GA
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Zip | 30306-2017
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Country | US
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Telephone | 678-984-9265
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Fax |
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Authorized Official
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Title or Position | PROVIDER
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Name | JESSICA GREATHOUSE
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Credential | LPC
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Telephone | 678-984-9265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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