Provider Demographics
NPI:1326484684
Name:AGAPE STORGE HEALTHCARE SERVICES, INC
Entity Type:Organization
Organization Name:AGAPE STORGE HEALTHCARE SERVICES, INC
Other - Org Name:SERENITY SAFE HAVEN OUTPATIENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAHIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCKERY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP, LCSW
Authorized Official - Phone:267-291-4513
Mailing Address - Street 1:93 OLD YORK RD
Mailing Address - Street 2:SUITE 1-526
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-3925
Mailing Address - Country:US
Mailing Address - Phone:267-808-8810
Mailing Address - Fax:
Practice Address - Street 1:8410 BUSTLETON AVE STE 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1924
Practice Address - Country:US
Practice Address - Phone:267-291-4513
Practice Address - Fax:215-701-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA142980251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health