Provider Demographics
NPI:1033488598
Name:L.I.G.H.T. COUNSELING CENTER
Entity Type:Organization
Organization Name:L.I.G.H.T. COUNSELING CENTER
Other - Org Name:LIGHT COUNSELING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:HORTENSE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT, CDP
Authorized Official - Phone:253-503-0236
Mailing Address - Street 1:9124 GRAVELLY LAKE DR SW
Mailing Address - Street 2:LAKES PLAZA SUITE 101
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3198
Mailing Address - Country:US
Mailing Address - Phone:253-503-0236
Mailing Address - Fax:253-503-0982
Practice Address - Street 1:9124 GRAVELLY LAKE DR SW
Practice Address - Street 2:LAKES PLAZA SUITE 101
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3198
Practice Address - Country:US
Practice Address - Phone:253-503-0236
Practice Address - Fax:253-503-0982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602933664251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA331-8907Medicaid
WA331-8907Medicaid