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General NPI Number Information
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NPI Number | 1366781866
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Entity Type | Organization
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Legal Business Name | SOVEREIGN JOURNEY L3C
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Dates
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Enumeration Date | 02/05/2013
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Last Update Date | 02/05/2013
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Provider Practice Location Address
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Address Line | 2444 MAIN ST
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City | BETHLEHEM
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State | NH
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Zip | 03574-4916
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Country | US
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Telephone | 603-869-7318
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 216
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City | BETHLEHEM
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State | NH
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Zip | 03574-0216
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Country | US
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Telephone | 603-869-7318
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KAREN E. FITZHUGH
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Credential | PH.D
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Telephone | 603-869-7318
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 03806
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License Number State | NH
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