Provider Demographics
NPI:1689228272
Name:LIGHT OF MINE PEDIATRIC AND ADOLESCENT THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:LIGHT OF MINE PEDIATRIC AND ADOLESCENT THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR, MOTR/L
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:918-520-6166
Mailing Address - Street 1:4517 S. YELLOW PINE AVE.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-5616
Mailing Address - Country:US
Mailing Address - Phone:918-520-6166
Mailing Address - Fax:
Practice Address - Street 1:4517 S. YELLOW PINE AVE.
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-5616
Practice Address - Country:US
Practice Address - Phone:918-520-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201224190AMedicaid