Provider Demographics
NPI:1003575911
Name:FLORIDA LIGHTHOUSE COUNSELING CENTER LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:FLORIDA LIGHTHOUSE COUNSELING CENTER LIMITED LIABILITY COMPANY
Other - Org Name:FLORIDA LIGHTHOUSE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:786-281-7681
Mailing Address - Street 1:3300 PORT ROYALE DR N APT 445
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7914
Mailing Address - Country:US
Mailing Address - Phone:786-281-7681
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:786-281-7681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107630000Medicaid