Provider Demographics
NPI:1730862491
Name:LEADING LIGHT MENTAL HEALTH CLINIC, INC
Entity type:Organization
Organization Name:LEADING LIGHT MENTAL HEALTH CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUAN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ELLERBE
Authorized Official - Suffix:
Authorized Official - Credentials:LSW, LMHC, PSYD
Authorized Official - Phone:774-220-4060
Mailing Address - Street 1:500 WESTGATE DR # 1006
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1855
Mailing Address - Country:US
Mailing Address - Phone:774-220-4060
Mailing Address - Fax:
Practice Address - Street 1:19 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-6898
Practice Address - Country:US
Practice Address - Phone:774-220-4060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health