Basic Information
| Provider Information | |||||||||
| NPI: | 1891213179 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUN BEHAVIORAL DELAWARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUN BEHAVIORAL DELAWARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077011938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327471800 | ||||||||
| FaxNumber: | 7327471818 | ||||||||
| Practice Location | |||||||||
| Address1: | 21655 BIDEN AVE | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199474573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327471800 | ||||||||
| FaxNumber: | 7327471818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2017 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROURKE | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT CORPORATE DEV | ||||||||
| AuthorizedOfficialTelephone: | 9724674461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
No ID Information.