Provider Demographics
NPI:1316009327
Name:THE DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:BRANDYWINE RTF
Other - Org Type:Other Name
Authorized Official - Title/Position:NATIONAL DIRECTOR AR
Authorized Official - Prefix:MS
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:GLENMOORE
Mailing Address - State:PA
Mailing Address - Zip Code:19343-0069
Mailing Address - Country:US
Mailing Address - Phone:610-942-5900
Mailing Address - Fax:610-942-5979
Practice Address - Street 1:160 DEVEREUX RD
Practice Address - Street 2:
Practice Address - City:GLENMOORE
Practice Address - State:PA
Practice Address - Zip Code:19343-1615
Practice Address - Country:US
Practice Address - Phone:610-942-5900
Practice Address - Fax:610-942-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA181910323P00000X
NJ1160323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000019130404Medicaid
NJ8385505Medicaid
MD196055500Medicaid
WV0002464001Medicaid
DC019198100Medicaid