Provider Demographics
NPI:1164501318
Name:STATE OF DELAWARE DSCYF
Entity Type:Organization
Organization Name:STATE OF DELAWARE DSCYF
Other - Org Name:ODESSA HOUSE RTC
Other - Org Type:Other Name
Authorized Official - Title/Position:CABINET SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:302-633-2500
Mailing Address - Street 1:493 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1463
Mailing Address - Country:US
Mailing Address - Phone:302-378-5226
Mailing Address - Fax:
Practice Address - Street 1:493 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1463
Practice Address - Country:US
Practice Address - Phone:302-378-5226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000489267Medicaid
DE0690004200OtherCYC