Basic Information
| Provider Information | |||||||||
| NPI: | 1801367883 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5703 GULF TECH DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395648238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288755447 | ||||||||
| FaxNumber: | 2288755448 | ||||||||
| Practice Location | |||||||||
| Address1: | 8905 OCEAN SPRINGS RD | ||||||||
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| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395644419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288755447 | ||||||||
| FaxNumber: | 2288755448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | CAMERON | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2283480694 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.