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General NPI Number Information
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NPI Number | 1699155226
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE BEHAVIORAL HEALTH, PLLC
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Dates
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Enumeration Date | 06/09/2015
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Last Update Date | 06/09/2015
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Provider Practice Location Address
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Address Line | 811 SHIP ST SUITE 4B
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-1171
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Country | US
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Telephone | 269-985-3618
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Fax | 269-609-6009
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Provider Business Mailing Address
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Address Line | 811 SHIP ST SUITE 4B
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-1171
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Country | US
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Telephone | 269-985-3618
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Fax | 269-609-6009
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Authorized Official
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Title or Position | OWNER/LICENSED PSYCHOLOGIST
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Name | MR. BRUCE PATRICK HACKWORTH
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Credential | PH.D.
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Telephone | 269-985-3618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 6301006344
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License Number State | MI
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