Provider Demographics
NPI:1609202878
Name:LIGHTHOUSE WELLNESS INSTITUTE
Entity Type:Organization
Organization Name:LIGHTHOUSE WELLNESS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-807-4520
Mailing Address - Street 1:1803 W 95TH ST
Mailing Address - Street 2:#117
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1103
Mailing Address - Country:US
Mailing Address - Phone:773-231-7707
Mailing Address - Fax:773-435-6693
Practice Address - Street 1:1803 W 95TH ST
Practice Address - Street 2:#117
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1103
Practice Address - Country:US
Practice Address - Phone:773-231-7707
Practice Address - Fax:773-435-6693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008341101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty