Healthcare Provider Details

I. General information

NPI: 1568810430
Provider Name (Legal Business Name): ABUNDANT LIFE COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 BLEVINS DR
NEW CASTLE DE
19720-4152
US

IV. Provider business mailing address

24 BLEVINS DR
NEW CASTLE DE
19720-4152
US

V. Phone/Fax

Practice location:
  • Phone: 302-983-6436
  • Fax:
Mailing address:
  • Phone: 302-983-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: ELLIS FAGBAMI
Title or Position: PRESIDENT
Credential:
Phone: 302-983-6436