Provider Demographics
NPI:1922353408
Name:LIGHTHOUSE COUNSELING AND MENTAL HEALHT SERVICES
Entity Type:Organization
Organization Name:LIGHTHOUSE COUNSELING AND MENTAL HEALHT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PERCY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC-MSHP,NCC
Authorized Official - Phone:615-692-4935
Mailing Address - Street 1:5165 BROOKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-5687
Mailing Address - Country:US
Mailing Address - Phone:615-692-4935
Mailing Address - Fax:855-261-6356
Practice Address - Street 1:310 UPTOWN SQ
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-0574
Practice Address - Country:US
Practice Address - Phone:615-692-4935
Practice Address - Fax:855-261-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000010821251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528221Medicaid