Provider Demographics
NPI:1316180565
Name:LIGHTHOUSE COUNSELING CENTER AND ASSOCIATED THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE COUNSELING CENTER AND ASSOCIATED THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA,MS,M ED, D MIN
Authorized Official - Phone:910-323-3368
Mailing Address - Street 1:901 ARSENAL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5398
Mailing Address - Country:US
Mailing Address - Phone:910-323-3368
Mailing Address - Fax:910-486-7000
Practice Address - Street 1:901 ARSENAL AVE STE 202
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5478
Practice Address - Country:US
Practice Address - Phone:910-323-3368
Practice Address - Fax:910-486-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008209Medicaid
NC8301795Medicaid