Provider Demographics
NPI:1235676214
Name:LIGHT, HAILEY
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:LIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 STRICKLAND AVE FL 33812
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4264
Mailing Address - Country:US
Mailing Address - Phone:863-644-8470
Mailing Address - Fax:
Practice Address - Street 1:5424 STRICKLAND AVE FL 33812
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4264
Practice Address - Country:US
Practice Address - Phone:863-644-8470
Practice Address - Fax:863-644-9590
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health