Provider Demographics
NPI:1578628392
Name:LIGHT PSYCHIATRIC SERVICES, PSC
Entity Type:Organization
Organization Name:LIGHT PSYCHIATRIC SERVICES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-244-5437
Mailing Address - Street 1:13113 EASTPOINT PARK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4191
Mailing Address - Country:US
Mailing Address - Phone:502-244-5437
Mailing Address - Fax:502-244-5003
Practice Address - Street 1:13113 EASTPOINT PARK BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4191
Practice Address - Country:US
Practice Address - Phone:502-244-5437
Practice Address - Fax:502-244-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36355305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH00141Medicare UPIN