=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215255393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHESDA FAMILY SERVICES FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2010
-----------------------------------------------------
Last Update Date | 01/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1807 S MAIN ST
-----------------------------------------------------
City | SAPULPA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74066-6531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-224-6349
-----------------------------------------------------
Fax | 918-224-7951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 REITZ BLVD STE 6
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-9220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
Fax | 570-523-0676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER, PRESIDENT
-----------------------------------------------------
Name | MR. DOMINIC P. HERBST
-----------------------------------------------------
Credential | M.A, M.S.
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------