Provider Demographics
NPI:1467730622
Name:LIGHTHOUSE BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BERKOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-346-4566
Mailing Address - Street 1:39W635 LORETTA DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-7613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2913
Practice Address - Country:US
Practice Address - Phone:847-347-4566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149014342251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health