Basic Information
Provider Information | |||||||||
NPI: | 1619980018 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FELLOWSHIP HEALTH RESOURCES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24 ALBION RD STE 420 | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | RI | ||||||||
PostalCode: | 028653744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013333980 | ||||||||
FaxNumber: | 4013348862 | ||||||||
Practice Location | |||||||||
Address1: | 23769 SHORTLY RD | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | DE | ||||||||
PostalCode: | 199474754 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3028567642 | ||||||||
FaxNumber: | 3028567658 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2006 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUGGAN | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4016424410 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 1062 | DE | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 000333061 | 05 | DE |   | MEDICAID |