Provider Demographics
NPI:1194446476
Name:WHITE LIGHT BEHAVIORAL HEATH COLUMBUS, LLC
Entity type:Organization
Organization Name:WHITE LIGHT BEHAVIORAL HEATH COLUMBUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-839-0925
Mailing Address - Street 1:4040 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1156
Mailing Address - Country:US
Mailing Address - Phone:614-350-4010
Mailing Address - Fax:
Practice Address - Street 1:4040 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1156
Practice Address - Country:US
Practice Address - Phone:615-775-1931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children