Provider Demographics
NPI:1578261855
Name:LIGHT AND LIFE THERAPY LLC
Entity Type:Organization
Organization Name:LIGHT AND LIFE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MDIV, CSOTP
Authorized Official - Phone:757-559-1690
Mailing Address - Street 1:3049 CLARKE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7923
Mailing Address - Country:US
Mailing Address - Phone:757-559-1690
Mailing Address - Fax:
Practice Address - Street 1:3049 CLARKE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7923
Practice Address - Country:US
Practice Address - Phone:757-559-1690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316466410Medicaid
VA1760198022Medicaid