Basic Information
Provider Information | |||||||||
NPI: | 1770879611 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHRISTIANA CARE HEALTH SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CCHS WELLNESS CTR MT PLEASANT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 HYGEIA DR | ||||||||
Address2: | SUITE 2502 | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197132049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026237362 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5201 WASHINGTON STREET EXT | ||||||||
Address2: | MT PLEASANT HIGH SCHOOL | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 198092156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027651100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2011 | ||||||||
LastUpdateDate: | 06/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CORRIGAN | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3026237203 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHRISTIANA CARE HEALTH SERVICES INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 363L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.