Provider Demographics
NPI:1093387250
Name:LIGHTHOUSE BEHAVIOR CENTER, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE BEHAVIOR CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CEO CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:281-881-7983
Mailing Address - Street 1:27 SE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-5346
Mailing Address - Country:US
Mailing Address - Phone:281-881-7983
Mailing Address - Fax:
Practice Address - Street 1:27 SE 24TH AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-5346
Practice Address - Country:US
Practice Address - Phone:281-881-7983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)