Provider Demographics
NPI:1003496167
Name:LIGHTHOUSE PROFESSIONAL SERVICES GROUP, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE PROFESSIONAL SERVICES GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO/LPC
Authorized Official - Prefix:
Authorized Official - First Name:SHARMEKIA
Authorized Official - Middle Name:LASHON
Authorized Official - Last Name:FORTSON-HOLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-392-5008
Mailing Address - Street 1:54 RYAN LOOP
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36869-7412
Mailing Address - Country:US
Mailing Address - Phone:706-392-5008
Mailing Address - Fax:
Practice Address - Street 1:2102 7TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3606
Practice Address - Country:US
Practice Address - Phone:706-392-5008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty