Healthcare Provider Details

I. General information

NPI: 1366999310
Provider Name (Legal Business Name): PSI ACIST PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 FOREST ST
DOVER DE
19904-3447
US

IV. Provider business mailing address

983 FOREST ST
DOVER DE
19904-3447
US

V. Phone/Fax

Practice location:
  • Phone: 302-480-9590
  • Fax: 302-480-9591
Mailing address:
  • Phone: 302-480-9590
  • Fax: 302-480-9591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1990037507
License Number StateDE

VIII. Authorized Official

Name: MARCIA LYNN CLENDANIEL
Title or Position: BILLING MANAGER
Credential:
Phone: 410-810-2465