Provider Demographics
NPI:1265242820
Name:HEADLIGHT MENTAL HEALTHCARE, LLC
Entity type:Organization
Organization Name:HEADLIGHT MENTAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:541-581-1080
Mailing Address - Street 1:555 SE MLK BLVD UNIT 105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2595
Mailing Address - Country:US
Mailing Address - Phone:541-581-1080
Mailing Address - Fax:541-588-6525
Practice Address - Street 1:555 SE MLK BLVD UNIT 105
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2595
Practice Address - Country:US
Practice Address - Phone:541-581-1080
Practice Address - Fax:541-588-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10003860OtherOREGON STATE BOARD OF NURSING
OR231782392OtherBUSINESS REGISTRY NUMBER