Provider Demographics
NPI:1205967759
Name:DAYSTAR CENTER FOR SPIRITUAL RECOVERY
Entity type:Organization
Organization Name:DAYSTAR CENTER FOR SPIRITUAL RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FERN
Authorized Official - Middle Name:ROBERTA
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CAADC
Authorized Official - Phone:717-230-9898
Mailing Address - Street 1:PO BOX 60574
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17106
Mailing Address - Country:US
Mailing Address - Phone:717-230-9898
Mailing Address - Fax:717-238-1793
Practice Address - Street 1:125 N. 18TH ST.
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17103
Practice Address - Country:US
Practice Address - Phone:717-230-9898
Practice Address - Fax:717-238-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA227077324500000X
PA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100035OtherCCBH IDENTIFIER
PA0018539150001Medicaid
PA227077OtherDEPT OF HEALTH FACILITY