1063480846 NPI number — LIGHTHOUSE YOUTH SERVICES INC.

Table of content: (NPI 1063480846)

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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