Provider Demographics
NPI:1134446958
Name:LIGHTED PATH PLLC
Entity type:Organization
Organization Name:LIGHTED PATH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DICICCO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LAC, CRC
Authorized Official - Phone:804-592-1205
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-0224
Mailing Address - Country:US
Mailing Address - Phone:804-592-1205
Mailing Address - Fax:866-388-8128
Practice Address - Street 1:1124 OAK ST
Practice Address - Street 2:SUITE 250
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4318
Practice Address - Country:US
Practice Address - Phone:804-592-1205
Practice Address - Fax:866-388-8128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health