Provider Demographics
NPI:1376360495
Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:THARP
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-319-7305
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-319-7305
Mailing Address - Fax:580-319-7328
Practice Address - Street 1:2425 W UNIVERSITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2970
Practice Address - Country:US
Practice Address - Phone:580-745-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care