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General NPI Number Information
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NPI Number | 1972774834
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
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Dates
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Enumeration Date | 03/19/2008
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 1551 PAYNE AVE
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City | SAINT PAUL
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State | MN
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Zip | 55130-3218
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Country | US
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Telephone | 763-780-3077
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Fax |
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Provider Business Mailing Address
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Address Line | 5155 E RIVER RD
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City | FRIDLEY
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State | MN
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Zip | 55421-1025
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Country | US
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Telephone | 763-780-3307
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Fax | 763-780-3306
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Authorized Official
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Title or Position | CEO
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Name | AARON J TRNKA
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Credential | M.A.
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Telephone | 763-780-3307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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