Provider Demographics
NPI:1578008124
Name:MARYHAVEN CENTER OF HOPE INC
Entity Type:Organization
Organization Name:MARYHAVEN CENTER OF HOPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-474-4120
Mailing Address - Street 1:51 TERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1331
Mailing Address - Country:US
Mailing Address - Phone:631-474-4120
Mailing Address - Fax:631-474-1312
Practice Address - Street 1:51 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1331
Practice Address - Country:US
Practice Address - Phone:631-474-4120
Practice Address - Fax:631-474-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9RDMedicaid