1972019941 NPI number — LIGHTHOUSE BEHAVIORAL SOLUTIONS

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 1972019941 NPI number — LIGHTHOUSE BEHAVIORAL SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE BEHAVIORAL SOLUTIONS
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:
1972019941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18002 IRVINE BLVD.
Provider Second Line Business Mailing Address:
SUITE 202C
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
657-333-6085
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18002 IRVINE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 202C
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
657-333-6085
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
POWERS
Authorized Official First Name:
MANUELA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
949-231-7979

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  BCBA1145779 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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