Healthcare Provider Details

I. General information

NPI: 1073768123
Provider Name (Legal Business Name): GAUDENZIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 W 10TH ST
WILMINGTON DE
19801-1424
US

IV. Provider business mailing address

106 W MAIN ST
NORRISTOWN PA
19401-4716
US

V. Phone/Fax

Practice location:
  • Phone: 302-737-4100
  • Fax: 302-655-5030
Mailing address:
  • Phone: 610-239-9600
  • Fax: 610-275-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2003107929
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2003107929
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MIKE WILLIAMS
Title or Position: SR CONTRACTING MANAGER
Credential:
Phone: 484-338-3731