Provider Demographics
NPI:1518535806
Name:RADIANT LIGHT BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:RADIANT LIGHT BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-373-4385
Mailing Address - Street 1:PO BOX 18361
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28218-0361
Mailing Address - Country:US
Mailing Address - Phone:704-222-2348
Mailing Address - Fax:
Practice Address - Street 1:625 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0470
Practice Address - Country:US
Practice Address - Phone:704-222-2348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty