Provider Demographics
NPI:1386219954
Name:THE LIGHTHOUSE MENTORING CENTER
Entity Type:Organization
Organization Name:THE LIGHTHOUSE MENTORING CENTER
Other - Org Name:LIGHTHOUSE MENTORING CENTER 4
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:922-628-1641
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-0085
Mailing Address - Country:US
Mailing Address - Phone:925-628-1641
Mailing Address - Fax:
Practice Address - Street 1:4343 BUCKSKIN DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-7470
Practice Address - Country:US
Practice Address - Phone:925-706-7270
Practice Address - Fax:925-706-7268
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LIGHTHOUSE MENTORING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-25
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness