Provider Demographics
NPI:1699135566
Name:LIGHTHOUSE INTEGRATIVE COUNSELING SERVICES LCSW MARRIAGE AND FAMILY TH
Entity type:Organization
Organization Name:LIGHTHOUSE INTEGRATIVE COUNSELING SERVICES LCSW MARRIAGE AND FAMILY TH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMFT
Authorized Official - Phone:631-478-3292
Mailing Address - Street 1:414 MAIN ST STE 203A
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1686
Mailing Address - Country:US
Mailing Address - Phone:631-478-3292
Mailing Address - Fax:631-476-1302
Practice Address - Street 1:414 MAIN ST STE 203A
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1686
Practice Address - Country:US
Practice Address - Phone:631-478-3292
Practice Address - Fax:631-476-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0736031041C0700X
NY000230106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty