Provider Demographics
NPI:1700501087
Name:LIGHTHOUSE PSYCHOLOGICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:LIGHTHOUSE PSYCHOLOGICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:586-244-8211
Mailing Address - Street 1:52188 VAN DYKE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3575
Mailing Address - Country:US
Mailing Address - Phone:586-244-8211
Mailing Address - Fax:
Practice Address - Street 1:52188 VAN DYKE AVE STE 300
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-3575
Practice Address - Country:US
Practice Address - Phone:586-244-8211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty