MEDICARE: LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS

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	251S00000X	Community/Behavioral Health Agency	100728830	OK

General Provider Information

NPI Number	:	1225378623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS

Provider Business Mailing Address
First Line	:	1219 K ST NW
Second Line	:	STE. #2
City	:	ARDMORE
State	:	OK
Zip	:	73401-1801
Country	:	US
Telephone Number	:	580-798-4523
Fax Number	:	580-319-5349

Provider Business Practice Location Address
First Line	:	1219 K ST NW
Second Line	:	STE. #2
City	:	ARDMORE
State	:	OK
Zip	:	73401-1801
Country	:	US
Telephone Number	:	580-798-4523
Fax Number	:	580-319-5349

Authorized Official
Title or Position	:	DEPUTY EXECUTIVE DIRECTOR
Name	:	DEANA THARP
Credential	:	LPC
Telephone Number	:	580-319-7305

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	05/20/2020

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