Provider Demographics
NPI:1114690401
Name:LIGHT AT THE END PLLC
Entity Type:Organization
Organization Name:LIGHT AT THE END PLLC
Other - Org Name:LIGHT AT THE END BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAVAUN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, PMHNP-BC
Authorized Official - Phone:314-882-5872
Mailing Address - Street 1:2135 E UNIVERSITY DR STE 120
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8335
Mailing Address - Country:US
Mailing Address - Phone:314-788-7651
Mailing Address - Fax:866-491-7389
Practice Address - Street 1:2135 E UNIVERSITY DR STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-8335
Practice Address - Country:US
Practice Address - Phone:314-788-7651
Practice Address - Fax:866-491-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-01
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)