=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861558983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE COUNSELING OF LAKE COUNTY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2007
-----------------------------------------------------
Last Update Date | 03/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 E HAWLEY ST SUITE 140
-----------------------------------------------------
City | MUNDELEIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60060-2494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-347-7367
-----------------------------------------------------
Fax | 224-513-4700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 KENLOCH AVE
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-1771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-347-7367
-----------------------------------------------------
Fax | 224-513-4700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. PAMELA ANN BRETTHAUER
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-347-7367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180005594
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------