Provider Demographics
NPI:1548428170
Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES INC
Entity type:Organization
Organization Name:LIGHTHOUSE PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:PAVEK
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:763-780-3307
Mailing Address - Street 1:1314 81ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1551 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-3218
Practice Address - Country:US
Practice Address - Phone:763-780-3077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health