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General NPI Number Information
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NPI Number | 1578008124
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Entity Type | Organization
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Legal Business Name | MARYHAVEN CENTER OF HOPE INC
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Dates
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Enumeration Date | 01/05/2017
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Last Update Date | 01/05/2017
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Provider Practice Location Address
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Address Line | 51 TERRYVILLE RD
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1331
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Country | US
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Telephone | 631-474-4120
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Fax | 631-474-1312
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Provider Business Mailing Address
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Address Line | 51 TERRYVILLE RD
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1331
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Country | US
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Telephone | 631-474-4120
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Fax | 631-474-1312
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | LEWIS GROSSMAN
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Credential |
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Telephone | 631-474-4120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State | NY
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