Provider Demographics
NPI:1871290890
Name:TWIN CITIES LIGHTHOUSE THERAPY, LLC
Entity type:Organization
Organization Name:TWIN CITIES LIGHTHOUSE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SELAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:763-260-4984
Mailing Address - Street 1:1750 MISSISSIPPI BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4774
Mailing Address - Country:US
Mailing Address - Phone:918-408-2687
Mailing Address - Fax:
Practice Address - Street 1:7362 UNIVERSITY AVE NE STE 209
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3151
Practice Address - Country:US
Practice Address - Phone:763-260-4984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health