=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821459272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY LIGHTHOUSE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2016
-----------------------------------------------------
Last Update Date | 03/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2498 N STOKESBERRY PL STE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-5842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-939-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2498 N STOKESBERRY PLACE #100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-939-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING/CREDENTIALING
-----------------------------------------------------
Name | KATY SIMMONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-452-6580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 4565
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------