=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093387250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE BEHAVIOR CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2021
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 SE 24TH AVE
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33062-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-881-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 SE 24TH AVE
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33062-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-881-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-CEO CO-FOUNDER
-----------------------------------------------------
Name | ANGELA L TALLO
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 281-881-7983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------