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General NPI Number Information
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NPI Number | 1134875727
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE SUPPORT SERVICES LLC
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Dates
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Enumeration Date | 02/23/2022
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Last Update Date | 08/10/2022
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Provider Practice Location Address
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Address Line | 7303 E MAIN ST STE 106
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City | MESA
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State | AZ
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Zip | 85207-8325
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Country | US
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Telephone | 480-332-0385
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Fax |
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Provider Business Mailing Address
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Address Line | 7303 E MAIN ST STE 106
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City | MESA
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State | AZ
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Zip | 85207-8325
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Country | US
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Telephone | 480-332-0385
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. JESSICA EVANS
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Credential |
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Telephone | 602-526-0302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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