Provider Demographics
NPI:1295060788
Name:LIGHT HOUSE FAMILY SERVICES
Entity type:Organization
Organization Name:LIGHT HOUSE FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER-SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-237-4066
Mailing Address - Street 1:3910 W DARROW ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6010
Mailing Address - Country:US
Mailing Address - Phone:602-237-4066
Mailing Address - Fax:602-237-4066
Practice Address - Street 1:3910 W DARROW ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6010
Practice Address - Country:US
Practice Address - Phone:602-237-4066
Practice Address - Fax:602-237-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH34173245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children