Healthcare Provider Details

I. General information

NPI: 1326186347
Provider Name (Legal Business Name): DIAMOND STATE YOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 LORE AVENUE
WILMINGTON DE
19809
US

IV. Provider business mailing address

1413 LORE AVENUE
WILMINGTON DE
19809
US

V. Phone/Fax

Practice location:
  • Phone: 302-762-6360
  • Fax: 302-762-6362
Mailing address:
  • Phone: 302-762-6360
  • Fax: 302-762-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number29182
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number29182
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number29182
License Number StateDE

VIII. Authorized Official

Name: MR. RUTH E. SARGEANT
Title or Position: EXECUTIVE DIRECTOR
Credential: MS
Phone: 302-762-6360