Healthcare Provider Details

I. General information

NPI: 1215120399
Provider Name (Legal Business Name): MARYHAVEN CENTER OF HOPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W MAIN ST
RIVERHEAD NY
11901-2801
US

IV. Provider business mailing address

51 TERRYVILLE ROAD
PORT JEFFERSON STATION NY
11776
US

V. Phone/Fax

Practice location:
  • Phone: 516-727-4044
  • Fax: 516-727-6531
Mailing address:
  • Phone: 631-474-4120
  • Fax: 631-474-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6825006A
License Number StateNY

VIII. Authorized Official

Name: LAURA PEPPER
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 631-474-4120