Provider Demographics
NPI:1972010064
Name:LIGHTHOUSE NEUROFEEDBACK & BEHAVIOR ANALYSIS, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE NEUROFEEDBACK & BEHAVIOR ANALYSIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOEB-WILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-449-6676
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:DACONO
Mailing Address - State:CO
Mailing Address - Zip Code:80514-0516
Mailing Address - Country:US
Mailing Address - Phone:720-449-6676
Mailing Address - Fax:303-833-4217
Practice Address - Street 1:3080 VALMONT RD STE 220
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2152
Practice Address - Country:US
Practice Address - Phone:720-772-7334
Practice Address - Fax:303-833-4217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011628101YP2500X
1-09-5794103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000153728Medicaid