MEDICARE: SHORE LIGHT BEHAVIORAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1114723616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORE LIGHT BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	2955 E 1ST AVE STE 200
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-5636
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 CALLE MACHO
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-3035
Country	:	US
Telephone Number	:	888-486-6717
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF COMPLIANCE
Name	:	STEPHEN VANHOOSER
Credential	:
Telephone Number	:	949-750-2014

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	02/24/2025

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