Provider Demographics
NPI:1639545965
Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED HEALTH SERVICE PSYCHOLOGIS
Authorized Official - Prefix:
Authorized Official - First Name:CALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-641-5367
Mailing Address - Street 1:510 24TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5106
Mailing Address - Country:US
Mailing Address - Phone:405-329-7923
Mailing Address - Fax:405-329-8815
Practice Address - Street 1:510 24TH AVE SW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5106
Practice Address - Country:US
Practice Address - Phone:405-329-7923
Practice Address - Fax:405-329-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5124101YP2500X
OK1237103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200447140 AMedicaid
OK200602650 AMedicaid
OK1639545965Medicaid
OK1073891594OtherINDIVIDUAL NPI
OK1235499773OtherINDIVIDUAL NPI
OK1235499773Medicaid
OK1073891594Medicaid
OK200602650 BMedicaid
OK200599660 AMedicaid