Provider Demographics
NPI:1750104881
Name:LIGHTHOUSE MENTORING CENTER
Entity type:Organization
Organization Name:LIGHTHOUSE MENTORING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:925-628-1641
Mailing Address - Street 1:2213 BUCHANAN RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4265
Mailing Address - Country:US
Mailing Address - Phone:925-628-1641
Mailing Address - Fax:
Practice Address - Street 1:2213 BUCHANAN RD # R107
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:925-529-4885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty