Provider Demographics
NPI:1790112746
Name:LIGHTHOUSE, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-788-5483
Mailing Address - Street 1:60 MELLOR AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5104
Mailing Address - Country:US
Mailing Address - Phone:410-788-5483
Mailing Address - Fax:410-788-5486
Practice Address - Street 1:60 MELLOR AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-5104
Practice Address - Country:US
Practice Address - Phone:410-788-5483
Practice Address - Fax:410-788-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-07
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBD70OtherCAREFIRST BCBS