Healthcare Provider Details

I. General information

NPI: 1053649178
Provider Name (Legal Business Name): SECOND HAVEN SERVICES FOR YOUTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 LAKESIDE DR
TOBYHANNA PA
18466-9792
US

IV. Provider business mailing address

PO BOX 329
MOUNT POCONO PA
18344-0329
US

V. Phone/Fax

Practice location:
  • Phone: 866-343-5509
  • Fax: 866-343-5509
Mailing address:
  • Phone: 866-343-5509
  • Fax: 866-343-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMD037460L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number223180
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number221370
License Number StatePA

VIII. Authorized Official

Name: MR. WILLIAM FREEMAN IV
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 866-343-5509