Provider Demographics
NPI:1366136541
Name:LIGHTHOUSE COUNSELING CENTER LLC
Entity type:Organization
Organization Name:LIGHTHOUSE COUNSELING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EARNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-297-0096
Mailing Address - Street 1:5201 SW WESTGATE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2424
Mailing Address - Country:US
Mailing Address - Phone:469-297-0096
Mailing Address - Fax:
Practice Address - Street 1:5201 SW WESTGATE DR STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2424
Practice Address - Country:US
Practice Address - Phone:469-297-0096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health