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General NPI Number Information
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NPI Number | 1326614678
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Entity Type | Organization
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Legal Business Name | LIGHT OF THE PINES, LLC
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 1705A FEAGIN DR # 164
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City | LUFKIN
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State | TX
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Zip | 75904-5535
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Country | US
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Telephone | 936-875-4555
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Fax | 936-236-4715
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Provider Business Mailing Address
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Address Line | PO BOX 154735
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City | LUFKIN
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State | TX
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Zip | 75915-4735
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Country | US
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Telephone | 936-875-4555
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Fax | 936-236-4715
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Authorized Official
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Title or Position | LICENSED ADMINISTRATOR
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Name | MRS. JENNIFER ANN YOUNG
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Credential | LPC
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Telephone | 936-875-4555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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