Provider Demographics
NPI:1962974766
Name:MARA'S LIGHTHOUSE COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:MARA'S LIGHTHOUSE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:INGENITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-352-3063
Mailing Address - Street 1:6015 MORROW ST E STE 109
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2125
Mailing Address - Country:US
Mailing Address - Phone:904-990-8105
Mailing Address - Fax:904-562-3359
Practice Address - Street 1:6015 MORROW ST E STE 109
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2125
Practice Address - Country:US
Practice Address - Phone:904-990-8105
Practice Address - Fax:904-562-3359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)