Healthcare Provider Details

I. General information

NPI: 1649815887
Provider Name (Legal Business Name): DTAC OF DELAWARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E LOOCKERMAN ST
DOVER DE
19901-8306
US

IV. Provider business mailing address

1950 RUTGERS UNIVERSITY BLVD STE 201
LAKEWOOD NJ
08701-4537
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MISS BROOK LEAH REICHENBACH
Title or Position: ADMINISTRATIVE SPECIALIST
Credential: MBA
Phone: 570-524-9986