Provider Demographics
NPI:1053649178
Name:SECOND HAVEN SERVICES FOR YOUTH INC.
Entity type:Organization
Organization Name:SECOND HAVEN SERVICES FOR YOUTH INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:IV
Authorized Official - Credentials:MBA
Authorized Official - Phone:866-343-5509
Mailing Address - Street 1:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:MOUNT POCONO
Mailing Address - State:PA
Mailing Address - Zip Code:18344-0329
Mailing Address - Country:US
Mailing Address - Phone:866-343-5509
Mailing Address - Fax:866-343-5509
Practice Address - Street 1:633 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-9792
Practice Address - Country:US
Practice Address - Phone:866-343-5509
Practice Address - Fax:866-343-5509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-01
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037460L103TP0016X
PA223180320900000X
PA221370322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Single Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty