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General NPI Number Information
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NPI Number | 1316543408
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE THERAPY ASSOCIATES PLLC
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Dates
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Enumeration Date | 12/05/2020
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Last Update Date | 12/05/2020
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Provider Practice Location Address
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Address Line | 123 S BROAD ST STE 2540
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City | PHILADELPHIA
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State | PA
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Zip | 19109-6601
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Country | US
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Telephone | 215-356-0340
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Fax |
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Provider Business Mailing Address
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Address Line | 123 S BROAD ST STE 2540
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City | PHILADELPHIA
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State | PA
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Zip | 19109-6601
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Country | US
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Telephone | 215-356-0340
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTOPHER GRUNDY
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Credential | PSYD
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Telephone | 215-356-0340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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