Provider Demographics
NPI:1336915495
Name:EASTERN LIGHT PSYCHIATRY
Entity Type:Organization
Organization Name:EASTERN LIGHT PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:208-313-9590
Mailing Address - Street 1:333 BLAKES HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:NH
Mailing Address - Zip Code:03261-3930
Mailing Address - Country:US
Mailing Address - Phone:208-313-9590
Mailing Address - Fax:
Practice Address - Street 1:333 BLAKES HILL RD
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:NH
Practice Address - Zip Code:03261-3930
Practice Address - Country:US
Practice Address - Phone:208-313-9590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health