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General NPI Number Information
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NPI Number | 1770446312
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Entity Type | Organization
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Legal Business Name | LIGHT BRIDGE COUNSELING GROUP LLC
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Dates
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Enumeration Date | 12/09/2025
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Last Update Date | 12/09/2025
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Provider Practice Location Address
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Address Line | 3238 NW 47TH AVE
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City | COCONUT CREEK
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State | FL
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Zip | 33063-1800
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Country | US
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Telephone | 954-205-6773
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Fax |
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Provider Business Mailing Address
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Address Line | 3238 NW 47TH AVE
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City | COCONUT CREEK
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State | FL
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Zip | 33063-1800
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Country | US
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Telephone | 954-205-6773
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GAVIN VANDERWAL MALCOLM
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Credential | LCSW
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Telephone | 954-205-6773
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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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