Provider Demographics
NPI:1194555771
Name:EASTERN LIGHT PSYCHIATRY
Entity type:Organization
Organization Name:EASTERN LIGHT PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:APRN
Authorized Official - Phone:208-313-9590
Mailing Address - Street 1:333 BLAKES HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:NH
Mailing Address - Zip Code:03261-3930
Mailing Address - Country:US
Mailing Address - Phone:208-313-9590
Mailing Address - Fax:603-696-3217
Practice Address - Street 1:20 FOUNDRY ST FL 2
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5419
Practice Address - Country:US
Practice Address - Phone:603-605-0882
Practice Address - Fax:603-696-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty