Provider Demographics
NPI:1740287622
Name:HARBORCREEK YOUTH SERVICES
Entity type:Organization
Organization Name:HARBORCREEK YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETULLA
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:814-899-7664
Mailing Address - Street 1:5712 IROQUOIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARBORCREEK
Mailing Address - State:PA
Mailing Address - Zip Code:16421
Mailing Address - Country:US
Mailing Address - Phone:814-899-7664
Mailing Address - Fax:814-899-3075
Practice Address - Street 1:5712 IROQUOIS AVE
Practice Address - Street 2:MST PROGRAM
Practice Address - City:HARBORCREEK
Practice Address - State:PA
Practice Address - Zip Code:16421-1009
Practice Address - Country:US
Practice Address - Phone:814-899-7664
Practice Address - Fax:814-899-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA001410380 0014251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001410380 0014Medicaid