Provider Demographics
NPI:1083365639
Name:LIGHTHOUSE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:LIGHTHOUSE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:DOLL
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-888-1444
Mailing Address - Street 1:24600 MANISTEE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1712
Mailing Address - Country:US
Mailing Address - Phone:313-888-1444
Mailing Address - Fax:
Practice Address - Street 1:910 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3216
Practice Address - Country:US
Practice Address - Phone:313-471-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty