Provider Demographics
NPI:1144276577
Name:LIGHTHOUSE THERAPY SERVICES, INC.
Entity type:Organization
Organization Name:LIGHTHOUSE THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-753-8499
Mailing Address - Street 1:822 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5433
Mailing Address - Country:US
Mailing Address - Phone:903-753-8499
Mailing Address - Fax:903-753-8502
Practice Address - Street 1:822 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5433
Practice Address - Country:US
Practice Address - Phone:903-753-8499
Practice Address - Fax:903-753-8502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0041LJOtherBLUE CROSS/BLUE SHIELD
TX0041LJOtherBLUE CROSS/BLUE SHIELD
TX00673YMedicare ID - Type Unspecified