1063480846 NPI number — LIGHTHOUSE YOUTH SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063480846 NPI number — LIGHTHOUSE YOUTH SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE YOUTH SERVICES INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063480846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 MADISON RD
Provider Second Line Business Mailing Address:
2ND, FLOOR
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45206-1776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-221-3350
Provider Business Mailing Address Fax Number:
513-221-3665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 N LUDLOW ST
Provider Second Line Business Practice Location Address:
SUITE 384
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45402-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-586-0435
Provider Business Practice Location Address Fax Number:
937-586-0441
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINTHER
Authorized Official First Name:
MARILON
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT, CFO
Authorized Official Telephone Number:
513-221-3350

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 0259 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11166 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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