Provider Demographics
NPI:1740672880
Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Entity type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL WELLNESS CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:THARP
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:580-319-7305
Mailing Address - Street 1:2425 W UNIVERSITY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2970
Mailing Address - Country:US
Mailing Address - Phone:580-924-7330
Mailing Address - Fax:580-924-2739
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:580-924-7331
Practice Address - Fax:580-924-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100728830AMedicaid