Healthcare Provider Details

I. General information

NPI: 1043882269
Provider Name (Legal Business Name): DIAMOND STATE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4023 KENNETT PIKE STE 275
WILMINGTON DE
19807-2018
US

IV. Provider business mailing address

4023 KENNETT PIKE STE 275
WILMINGTON DE
19807-2018
US

V. Phone/Fax

Practice location:
  • Phone: 267-736-0182
  • Fax:
Mailing address:
  • Phone: 267-736-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN T. FOX
Title or Position: CEO
Credential: LPC
Phone: 302-213-9445