Provider Demographics
NPI:1891986824
Name:BEACON LIGHT BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:BEACON LIGHT BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:814-362-6565
Mailing Address - Street 1:800 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-3278
Mailing Address - Country:US
Mailing Address - Phone:814-362-5250
Mailing Address - Fax:814-362-2185
Practice Address - Street 1:945 SOUTH AVE.
Practice Address - Street 2:
Practice Address - City:CUSTER CITY
Practice Address - State:PA
Practice Address - Zip Code:16725
Practice Address - Country:US
Practice Address - Phone:814-362-6565
Practice Address - Fax:814-362-6415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015091251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health