Provider Demographics
NPI:1942605415
Name:SERENITY SAFE HAVEN OUTPATIENT CLINIC
Entity type:Organization
Organization Name:SERENITY SAFE HAVEN OUTPATIENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:TAHIRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOCKERY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:267-808-8810
Mailing Address - Street 1:93 OLD YORK RD STE 1-526
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-3925
Mailing Address - Country:US
Mailing Address - Phone:
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:267-808-8810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGAPE STORGE HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011319251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health