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General NPI Number Information
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NPI Number | 1326965674
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE YOUTH SERVICES LLC.
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Dates
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Enumeration Date | 06/29/2026
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Last Update Date | 06/29/2026
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Provider Practice Location Address
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Address Line | 139 DEER RUN RD
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City | DANVILLE
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State | VA
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Zip | 24540-2863
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Country | US
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Telephone | 863-840-2408
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Fax |
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Provider Business Mailing Address
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Address Line | 3261 HUFFINES DR
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City | BURLINGTON
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State | NC
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Zip | 27217-8212
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Country | US
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Telephone | 863-840-2408
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JACKSON CLERVEAU
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Credential |
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Telephone | 863-840-2408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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