Provider Demographics
NPI:1013602242
Name:PATHOS COUNSELING AND WELLNESS LLC
Entity Type:Organization
Organization Name:PATHOS COUNSELING AND WELLNESS LLC
Other - Org Name:LIGHTHOUSE COUNSELING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:RETA
Authorized Official - Middle Name:
Authorized Official - Last Name:SELITTO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:434-844-1206
Mailing Address - Street 1:4445 CORPORATION LN STE 264
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3671
Mailing Address - Country:US
Mailing Address - Phone:434-844-1206
Mailing Address - Fax:
Practice Address - Street 1:452 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-8308
Practice Address - Country:US
Practice Address - Phone:434-844-1206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932870748Medicaid