Basic Information
| Provider Information | |||||||||
| NPI: | 1699743740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LIGHTHOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431300215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406892558 | ||||||||
| FaxNumber: | 7406892616 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 N BROAD ST | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431303004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406874423 | ||||||||
| FaxNumber: | 7406871048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PELLETIER-WALKER | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7046892558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MSW, LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MC160400 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MC 160400 | 05 | OH | MEDICAID |