| Organization Name: | LIGHTHOUSE FOR RECOVERY, LLC |
| NPI Number: | 1013298058 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | WILLIAM C. SLAVEN (EXECUTIVE DIRECTOR) |
| Mailing Address: | 1135 Yellowstone Ave Suite D Pocatello |
| State: | ID US |
| Postal Code: | 832015082 |
| Phone Number: | 2082322908 |
| Fax Number: | 2082325423 |
| NPI Enumeration Date: | 09/05/2011 |
| NPI Last Update Date: | 09/05/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | LCSW 28016 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |