Provider Demographics
NPI:1205472321
Name:BEACON OF LIGHT COUNSELING LLC
Entity type:Organization
Organization Name:BEACON OF LIGHT COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:LATEASA
Authorized Official - Middle Name:LINETTE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-515-2055
Mailing Address - Street 1:PO BOX 1264
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1264
Mailing Address - Country:US
Mailing Address - Phone:231-515-2055
Mailing Address - Fax:
Practice Address - Street 1:1515 E LAKETON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442
Practice Address - Country:US
Practice Address - Phone:231-515-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-24
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty