Basic Information
| Provider Information | |||||||||
| NPI: | 1316180565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE COUNSELING CENTER AND ASSOCIATED THERAPEUTIC SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | 9104867000 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | 9104867000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2009 | ||||||||
| LastUpdateDate: | 07/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | CHESTER | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9103233368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MA,MS,M ED, D. MIN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 8301795 | 05 | NC | MEDICAID | 6008209 | 05 | NC | MEDICAID |