Provider Demographics
NPI:1477937522
Name:LIGHTHOUSE NEUROFEEDBACK & BEHAVIOR ANALYSIS, INC.
Entity type:Organization
Organization Name:LIGHTHOUSE NEUROFEEDBACK & BEHAVIOR ANALYSIS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:HUI-CHUNG
Authorized Official - Middle Name:JACQUELINA
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-318-8088
Mailing Address - Street 1:720 100 YEARPARTY CT STE 200
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-8591
Mailing Address - Country:US
Mailing Address - Phone:720-449-6676
Mailing Address - Fax:303-374-5224
Practice Address - Street 1:720 100 YEARPARTY CT STE 200
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-8591
Practice Address - Country:US
Practice Address - Phone:720-449-6676
Practice Address - Fax:303-374-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-09-5794103K00000X
103TP2701X, 106S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000153728Medicaid