=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245983824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON OF LIGHT BEHAVIORAL HEALTH, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2022
-----------------------------------------------------
Last Update Date | 09/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W DIXIE AVE STE 11
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-900-1358
-----------------------------------------------------
Fax | 844-444-1150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W DIXIE AVE STE 11
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-900-1358
-----------------------------------------------------
Fax | 844-444-1150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. NATASHA REGINA PORTER
-----------------------------------------------------
Credential | PHD, LMFT, LPCC-S
-----------------------------------------------------
Telephone | 270-900-1358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------