Provider Demographics
NPI:1902454689
Name:LIGHT SOURCE LLC
Entity Type:Organization
Organization Name:LIGHT SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-444-9934
Mailing Address - Street 1:114 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2251
Mailing Address - Country:US
Mailing Address - Phone:618-444-9934
Mailing Address - Fax:
Practice Address - Street 1:114 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2251
Practice Address - Country:US
Practice Address - Phone:618-444-9934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty