Provider Demographics
NPI:1265451280
Name:LIGHTHOUSE CLINIC, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAVA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENDELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-964-9200
Mailing Address - Street 1:2577 N DOWNER AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4253
Mailing Address - Country:US
Mailing Address - Phone:414-964-9200
Mailing Address - Fax:414-964-4816
Practice Address - Street 1:2577 N DOWNER AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4253
Practice Address - Country:US
Practice Address - Phone:414-964-9200
Practice Address - Fax:414-964-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42149800Medicaid
WI000044635Medicare PIN
WI000084452Medicare PIN