Provider Demographics
NPI:1093212466
Name:LIGHTED PATH THERAPY SERVICES
Entity Type:Organization
Organization Name:LIGHTED PATH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HOLL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:907-312-1202
Mailing Address - Street 1:PO BOX 871336
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-312-1202
Mailing Address - Fax:855-553-8083
Practice Address - Street 1:901 N. LEATHERLEAF LOOP SUITE 103
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-312-1202
Practice Address - Fax:855-553-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty