=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578922985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETHESDA FAMILY SERVICES FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2016
-----------------------------------------------------
Last Update Date | 02/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 REITZ BLVD SUITE 6
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-9220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 REITZ BLVD SUITE 6
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-9220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. GINALYN ELIZABETH BAVERO
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 570-523-0605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PC007996
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------