Provider Demographics
NPI:1063031011
Name:LIGHTHOUSE HOLISTIC WELLNESS
Entity Type:Organization
Organization Name:LIGHTHOUSE HOLISTIC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-984-9265
Mailing Address - Street 1:1145 ZONOLITE RD NE STE 10
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-2017
Mailing Address - Country:US
Mailing Address - Phone:678-984-9265
Mailing Address - Fax:
Practice Address - Street 1:1145 ZONOLITE RD NE STE 10
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-2017
Practice Address - Country:US
Practice Address - Phone:678-984-9265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health