Healthcare Provider Details

I. General information

NPI: 1487982880
Provider Name (Legal Business Name): SELF REALIZATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SLEEPY HOLLOW DR STE 200
MIDDLETOWN DE
19709-5841
US

IV. Provider business mailing address

9 MORNING DEW DR
MIDDLETOWN DE
19709-2419
US

V. Phone/Fax

Practice location:
  • Phone: 302-312-8221
  • Fax:
Mailing address:
  • Phone: 302-312-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberB10000757
License Number StateDE

VIII. Authorized Official

Name: DR. EARL WALKER JR.
Title or Position: EXECUTIVE DIRECTOR
Credential: ED.D.
Phone: 302-312-8221