MEDICARE: LIGHTHOUSE PSYCHOLOGICAL SERVICES INC

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

General Provider Information

NPI Number	:	1548428170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE PSYCHOLOGICAL SERVICES INC

Provider Business Mailing Address
First Line	:	1314 81ST AVE NE
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-2116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 PAYNE AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3218
Country	:	US
Telephone Number	:	763-780-3077
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MRS. MOLLY PAVEK OLSON
Credential	:	MA
Telephone Number	:	763-780-3307

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	08/12/2021

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Directions to “LIGHTHOUSE PSYCHOLOGICAL SERVICES INC ” Practice Location

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