Basic Information
| Provider Information | |||||||||
| NPI: | 1710511100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE THERAPY & DIAGNOSTIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5108 KUHINA PL | ||||||||
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| City: | PRINCEVILLE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967225116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086520466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2509 KOLO ROAD | ||||||||
| Address2: | |||||||||
| City: | KILAUEA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086520466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2020 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | LUDOLPH | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 8086520466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.