Provider Demographics
NPI:1154679926
Name:LIGHTING THE WAY INTERVENTION SERVICES
Entity type:Organization
Organization Name:LIGHTING THE WAY INTERVENTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:TASHELL
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-596-3590
Mailing Address - Street 1:4286 MEMORIAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1221
Mailing Address - Country:US
Mailing Address - Phone:678-596-3590
Mailing Address - Fax:404-389-0885
Practice Address - Street 1:5875 WESTCHASE ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30336-2912
Practice Address - Country:US
Practice Address - Phone:678-596-3590
Practice Address - Fax:404-389-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health