=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679394415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY THERAPY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 N DUPONT HWY APT J103
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-7806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-219-1255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 N DUPONT HWY APT J103
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-7806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-219-1255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | GARY W STANEK
-----------------------------------------------------
Credential | MS, MA, LMFT
-----------------------------------------------------
Telephone | 203-219-1255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------