Provider Demographics
NPI:1699155226
Name:LIGHTHOUSE BEHAVIORAL HEALTH, PLLC
Entity type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HACKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-985-3618
Mailing Address - Street 1:811 SHIP ST
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1171
Mailing Address - Country:US
Mailing Address - Phone:269-985-3618
Mailing Address - Fax:269-609-6009
Practice Address - Street 1:811 SHIP ST
Practice Address - Street 2:SUITE 4B
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1171
Practice Address - Country:US
Practice Address - Phone:269-985-3618
Practice Address - Fax:269-609-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006344103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty