Provider Demographics
NPI:1972774834
Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRNKA
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:763-780-3307
Mailing Address - Street 1:5155 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1025
Mailing Address - Country:US
Mailing Address - Phone:763-780-3307
Mailing Address - Fax:763-780-3306
Practice Address - Street 1:1551 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-3218
Practice Address - Country:US
Practice Address - Phone:763-780-3077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN964912100OtherMHCP PROVIDER ID #