Provider Demographics
NPI:1982389003
Name:LIGHTHOUSE FAMILY THERAPY PROF LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE FAMILY THERAPY PROF LLC
Other - Org Name:LIGHTHOUSE WHOLEHEALTH FAMILY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:303-929-6743
Mailing Address - Street 1:1785 NIGHFALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550
Mailing Address - Country:US
Mailing Address - Phone:303-929-6743
Mailing Address - Fax:
Practice Address - Street 1:300 E HORSETOOTH RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3154
Practice Address - Country:US
Practice Address - Phone:303-929-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-16
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000218730Medicaid