1578067930 NPI number — LIGHTHOUSE CLINICAL SOCIAL WORK, LLC

Table of content: (NPI 1578067930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578067930 NPI number — LIGHTHOUSE CLINICAL SOCIAL WORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE CLINICAL SOCIAL WORK, LLC
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:
LIGHTHOUSE CLINICAL SOCIAL WORK
Provider Other Organization Name Type Code:
3
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:
1578067930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 W DUBLIN DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35758-3157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-929-5507
Provider Business Mailing Address Fax Number:
888-440-7284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W DUBLIN DR STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35758-3157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-929-5507
Provider Business Practice Location Address Fax Number:
888-440-7284
Provider Enumeration Date:
03/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DUQUETTE
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER/PSYCHOTHERAPIST
Authorized Official Telephone Number:
256-929-5507

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: 1626 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 51526789 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11817512 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q35592 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51527591 . This is a "FEDERAL BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1073552089 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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