Provider Demographics
NPI:1164793840
Name:GUARDIAN LIGHTHOUSE
Entity Type:Organization
Organization Name:GUARDIAN LIGHTHOUSE
Other - Org Name:GUARDIAN YOUTH AND FAMILY COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CADC
Authorized Official - Phone:847-613-4626
Mailing Address - Street 1:PO BOX 6181
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-6181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 N MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5176
Practice Address - Country:US
Practice Address - Phone:847-613-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22184101YA0400X
IL22773101YA0400X
IL180005697101YM0800X
IL180005201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty