| Organization Name: | LIGHT HOUSE GROUP |
| NPI Number: | 1225166069 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES DAVENPORT (PRESIDENT) |
| Mailing Address: | 206 Wapiti Dr 108 Ashton Pl Spring Lake |
| State: | NC US |
| Postal Code: | 283901530 |
| Phone Number: | 9104970299 |
| Fax Number: | 9104970297 |
| NPI Enumeration Date: | 03/02/2007 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 322D00000X |
| License Number: | MHL -026-805 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | NC |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Residential Treatment Facility, Emotionally Disturbed Children |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider facility or distinct part of the organization which renders an interdisciplinary program of mental health treatment to individuals under 21 years of age who have persistent dysfunction in major life areas. The dysfunction is of an extent and pervasiveness that requires a protected and highly structured therapeutic environment. These organizations, or distinct part of organizations, exclude those that provide acute psychiatric care, partial hospitalization, group living, therapeutic schooling, primary diagnosis substance abuse disorder treatment, or primary diagnosis mental retardation or developmental disability treatment. |