1902440886 NPI number — LIGHTHOUSE BEHAVIORAL HEALTH CENTER LLC RESIDENTIAL SUD

Table of content: (NPI 1902440886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902440886 NPI number — LIGHTHOUSE BEHAVIORAL HEALTH CENTER LLC RESIDENTIAL SUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE BEHAVIORAL HEALTH CENTER LLC RESIDENTIAL SUD
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:
1902440886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1119 E MONUMENT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21202-4119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-708-5056
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1723 GWYNNS FALLS PKWY
Provider Second Line Business Practice Location Address:
1ST AND 2ND FLOOR
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21217-2098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-400-6206
Provider Business Practice Location Address Fax Number:
667-400-6206
Provider Enumeration Date:
11/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HOLMES
Authorized Official First Name:
VERNON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
202-651-1857

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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