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NPI Code Detail

MEDICARE: LIGHTHOUSE CLINIC, LLC

MEDICARE: LIGHTHOUSE CLINIC, 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
11041C0700XClinical Social Worker
2103G00000XClinical Neuropsychologist
3133V00000XRegistered Dietitian
42084P0800XPsychiatry Physician
52084P0804XChild & Adolescent Psychiatry Physician
6101YM0800XMental Health Counselor
7101YP2500XProfessional Counselor
8103T00000XPsychologist

General Provider Information

NPI Number : 1912216219
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIGHTHOUSE CLINIC, LLC
Provider Business Mailing Address
First Line : 2524 E WEBSTER PL STE 203
Second Line :
City : MILWAUKEE
State : WI
Zip : 53211-4257
Country : US
Telephone Number : 414-964-9200
Fax Number : 414-964-4816
Provider Business Practice Location Address
First Line : 2524 E WEBSTER PL
Second Line : SUITE 203
City : MILWAUKEE
State : WI
Zip : 53211-4256
Country : US
Telephone Number : 414-964-9200
Fax Number : 414-964-4816
Authorized Official
Title or Position : OWNER/MANAGER
Name : PAULA TUDOROF
Credential :
Telephone Number : 323-447-9507
Provider Enumeration Date : 10/04/2010
Last Update Date : 03/04/2026

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Directions to “LIGHTHOUSE CLINIC, LLC ” Practice Location

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