Healthcare Provider Details

I. General information

NPI: 1063982114
Provider Name (Legal Business Name): A CENTER FOR MENTAL WELLNESS COMMUNITY SUPPORT PROGRAMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W LOOCKERMAN ST
DOVER DE
19904-7325
US

IV. Provider business mailing address

121 W LOOCKERMAN ST
DOVER DE
19904-7325
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-1397
  • Fax: 302-674-1602
Mailing address:
  • Phone: 302-674-1397
  • Fax: 302-266-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN ELIZABETH TINSLEY
Title or Position: MANAGING MEMBER
Credential: LPCMH
Phone: 302-674-1397