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General NPI Number Information
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NPI Number | 1932057239
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Entity Type | Organization
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Legal Business Name | PHOENIX LIGHTHOUSE
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Dates
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Enumeration Date | 03/20/2026
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Last Update Date | 03/20/2026
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Provider Practice Location Address
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Address Line | 5766 SOMERSET BLVD
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City | BARGERSVILLE
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State | IN
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Zip | 46106
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Country | US
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Telephone | 478-279-9802
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Fax |
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Provider Business Mailing Address
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Address Line | 1710 KELLER PKWY # 2011
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City | KELLER
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State | TX
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Zip | 76248-3749
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Country | US
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Telephone | 478-279-9802
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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 | KAMAU SULLIVAN
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Credential | LMSW
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Telephone | 317-409-5755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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