=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356677413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHESDA FAMILY SERVICE FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2009
-----------------------------------------------------
Last Update Date | 10/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 BULL RUN XING SUITE ONE
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-6725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
Fax | 570-523-0676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 BULL RUN XING SUITE ONE
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-6725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
Fax | 570-523-0676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DOMINIC P HERBST
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------