Provider Demographics
NPI:1366000945
Name:GUIDING LIGHT HOME FOR BOYS, INC
Entity type:Organization
Organization Name:GUIDING LIGHT HOME FOR BOYS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHUGELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-775-3748
Mailing Address - Street 1:25123 MIDDLEBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-9204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26624 SAFFRON CIR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3834
Practice Address - Country:US
Practice Address - Phone:951-775-3748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty