Healthcare Provider Details

I. General information

NPI: 1366781866
Provider Name (Legal Business Name): SOVEREIGN JOURNEY L3C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 MAIN ST
BETHLEHEM NH
03574-4916
US

IV. Provider business mailing address

PO BOX 216
BETHLEHEM NH
03574-0216
US

V. Phone/Fax

Practice location:
  • Phone: 603-869-7318
  • Fax:
Mailing address:
  • Phone: 603-869-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number03806
License Number StateNH

VIII. Authorized Official

Name: KAREN E. FITZHUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D
Phone: 603-869-7318