Provider Demographics
NPI:1912216219
Name:LIGHTHOUSE CLINIC, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE CLINIC, LLC
Other - Org Name:LHC AQUISITIONS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUDOROF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-447-9507
Mailing Address - Street 1:2524 E WEBSTER PL STE 203
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4257
Mailing Address - Country:US
Mailing Address - Phone:414-964-9200
Mailing Address - Fax:414-964-4816
Practice Address - Street 1:2524 E WEBSTER PL
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4256
Practice Address - Country:US
Practice Address - Phone:414-964-9200
Practice Address - Fax:414-964-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty