Provider Demographics
NPI:1609015437
Name:LIGHTHOUSE ADDICTION RECOVERY CENTRE
Entity Type:Organization
Organization Name:LIGHTHOUSE ADDICTION RECOVERY CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BIGELOW
Authorized Official - Suffix:
Authorized Official - Credentials:CDP RC
Authorized Official - Phone:360-332-8509
Mailing Address - Street 1:383 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-4108
Mailing Address - Country:US
Mailing Address - Phone:360-332-8549
Mailing Address - Fax:360-332-8089
Practice Address - Street 1:383 MARTIN ST
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4108
Practice Address - Country:US
Practice Address - Phone:360-332-8549
Practice Address - Fax:360-332-8089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37131800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA37131800OtherDEPARTMENT OF ALCHOHOL AND SUBSTANCE ABUSE