MEDICARE: LIGHTHOUSE FAMILY SERVICES 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	C-10254	NM

General Provider Information

NPI Number	:	1407359136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE FAMILY SERVICES LLC

Provider Business Mailing Address
First Line	:	3404 DEL RIO CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-4938
Country	:	US
Telephone Number	:	575-312-8257
Fax Number	:

Provider Business Practice Location Address
First Line	:	1485 N MAIN ST STE C
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-1182
Country	:	US
Telephone Number	:	575-312-8257
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ISABEL GONZALES
Credential	:	LCSW
Telephone Number	:	575-312-8257

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	03/08/2018

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