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General NPI Number Information
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NPI Number | 1609202878
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE WELLNESS INSTITUTE
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Dates
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Enumeration Date | 09/19/2013
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Last Update Date | 09/19/2013
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Provider Practice Location Address
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Address Line | 1803 W 95TH ST #117
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City | CHICAGO
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State | IL
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Zip | 60643-1103
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Country | US
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Telephone | 773-231-7707
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Fax | 773-435-6693
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Provider Business Mailing Address
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Address Line | 1803 W 95TH ST #117
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City | CHICAGO
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State | IL
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Zip | 60643-1103
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Country | US
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Telephone | 773-231-7707
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Fax | 773-435-6693
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Authorized Official
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Title or Position | CLINICAL COUNSELOR
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Name | JENNIFER L STEVENSON
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Credential | LCPC
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Telephone | 773-807-4520
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.008341
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License Number State | IL
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