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General NPI Number Information
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NPI Number | 1366000945
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Entity Type | Organization
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Legal Business Name | GUIDING LIGHT HOME FOR BOYS, INC
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Dates
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Enumeration Date | 05/30/2019
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Last Update Date | 06/17/2019
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Provider Practice Location Address
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Address Line | 26624 SAFFRON CIR
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City | MORENO VALLEY
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State | CA
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Zip | 92555-3834
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Country | US
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Telephone | 951-775-3748
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Fax |
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Provider Business Mailing Address
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Address Line | 25123 MIDDLEBROOK WAY
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City | MORENO VALLEY
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State | CA
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Zip | 92551-9204
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | SHUGELLA WEAVER THOMAS
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Credential |
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Telephone | 951-775-3748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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