Healthcare Provider Details

I. General information

NPI: 1104558097
Provider Name (Legal Business Name): ISAIAH HOME 613 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 CHAPMAN RD STE 104B
NEWARK DE
19702-5410
US

IV. Provider business mailing address

260 CHAPMAN RD STE 104B
NEWARK DE
19702-5410
US

V. Phone/Fax

Practice location:
  • Phone: 302-499-2326
  • Fax:
Mailing address:
  • Phone: 302-499-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: EBONI FOUNTAIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 302-275-8938