MEDICARE: PORCH LIGHT LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1124645999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORCH LIGHT LLC

Provider Business Mailing Address
First Line	:	6263 W TWAIN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-1153
Country	:	US
Telephone Number	:	443-449-9034
Fax Number	:

Provider Business Practice Location Address
First Line	:	6263 W TWAIN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-1153
Country	:	US
Telephone Number	:	443-449-9034
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. LORI CAMPBELL
Credential	:	LCSW
Telephone Number	:	443-449-9034

Provider Enumeration Date	:	06/28/2020
Last Update Date	:	01/25/2021

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Directions to “PORCH LIGHT LLC ” Practice Location

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