Basic Information
| Provider Information | |||||||||
| NPI: | 1578067930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIGHTHOUSE CLINICAL SOCIAL WORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1643 SLAUGHTER RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357588692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568958148 | ||||||||
| FaxNumber: | 2564898148 | ||||||||
| Practice Location | |||||||||
| Address1: | 1643 SLAUGHTER RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357588692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568958148 | ||||||||
| FaxNumber: | 2564898148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUQUETTE | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2568958148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | L.I.C.S.W., P.I.P. | ||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1626 | AL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 51526789 | 01 | BCBS | OTHER | 51527591 | 01 | FEDERAL BCBS | OTHER |