=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083682850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE YOUTH SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2006
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E MCMILLAN ST FL 2
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45206-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-487-7106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E MCMILLAN ST
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45206-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-487-7106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, CFO
-----------------------------------------------------
Name | MRS. THUY KOLIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-487-7106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0259
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------