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General NPI Number Information
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NPI Number | 1750104881
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE MENTORING CENTER
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Dates
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Enumeration Date | 11/06/2024
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 2213 BUCHANAN RD # R107
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City | ANTIOCH
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State | CA
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Zip | 94509-4265
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Country | US
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Telephone | 925-529-4885
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Fax |
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Provider Business Mailing Address
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Address Line | 2213 BUCHANAN RD STE 107
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City | ANTIOCH
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State | CA
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Zip | 94509-4265
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Country | US
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Telephone | 925-628-1641
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MS. PHYLLIS RITTER
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Credential | LMFT
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Telephone | 925-628-1641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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