=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881607299
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FELLOWSHIP HEALTH RESOURCES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18090 HARBESON RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19968-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-684-4400
-----------------------------------------------------
Fax | 302-684-2943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 ALBION RD STE 420
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02865-3744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-333-3980
-----------------------------------------------------
Fax | 401-334-8862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR CONTRACTS & CREDENTIALING
-----------------------------------------------------
Name | DONNA BUSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 445-206-3028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 1703
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------