Provider Demographics
NPI:1215255393
Name:BETHESDA FAMILY SERVICES FOUNDATION
Entity type:Organization
Organization Name:BETHESDA FAMILY SERVICES FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERBST
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MS
Authorized Official - Phone:570-523-0605
Mailing Address - Street 1:260 REITZ BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9220
Mailing Address - Country:US
Mailing Address - Phone:570-523-0605
Mailing Address - Fax:570-523-0676
Practice Address - Street 1:1807 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6531
Practice Address - Country:US
Practice Address - Phone:918-224-6349
Practice Address - Fax:918-224-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children