Provider Demographics
NPI:1518401900
Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES... A BEACON OF LIGHT
Entity Type:Organization
Organization Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES... A BEACON OF LIGHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHONTINESE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:209-451-9475
Mailing Address - Street 1:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CA
Mailing Address - Zip Code:95368-0556
Mailing Address - Country:US
Mailing Address - Phone:209-451-9475
Mailing Address - Fax:209-451-9475
Practice Address - Street 1:2291 W MARCH LN STE E-101
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6652
Practice Address - Country:US
Practice Address - Phone:209-451-9475
Practice Address - Fax:209-451-9475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21817251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health