Healthcare Provider Details

I. General information

NPI: 1215255393
Provider Name (Legal Business Name): BETHESDA FAMILY SERVICES FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 S MAIN ST
SAPULPA OK
74066-6531
US

IV. Provider business mailing address

260 REITZ BLVD STE 6
LEWISBURG PA
17837-9220
US

V. Phone/Fax

Practice location:
  • Phone: 918-224-6349
  • Fax: 918-224-7951
Mailing address:
  • Phone: 570-523-0605
  • Fax: 570-523-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DOMINIC P. HERBST
Title or Position: FOUNDER, PRESIDENT
Credential: M.A, M.S.
Phone: 570-523-0605