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General NPI Number Information
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NPI Number | 1366622110
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Entity Type | Organization
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Legal Business Name | OVERBROOK THERAPY ASSOCIATES
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Dates
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Enumeration Date | 11/09/2007
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Last Update Date | 11/09/2007
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Provider Practice Location Address
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Address Line | 1015 WEST 24TH STREET
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City | WILMINGTON
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State | DE
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Zip | 19802
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Country | US
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Telephone | 302-834-5433
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 53726
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City | PHILADELPHIA
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State | PA
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Zip | 19105-3726
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Country | US
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Telephone | 215-510-1063
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. CARISSA Y FERGUSON
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Credential | PSY.D, LCSW
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Telephone | 215-510-1063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | Q10000903
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License Number State | DE
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