=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578261855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHT AND LIFE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2023
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6350 CENTER DR STE 106
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-559-1690
-----------------------------------------------------
Fax | 757-767-7921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3049 CLARKE DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-7923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-559-1690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN DIAMANTIS
-----------------------------------------------------
Credential | LCSW, MDIV, CSOTP
-----------------------------------------------------
Telephone | 757-559-1690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------