Provider Demographics
NPI:1326489451
Name:PAMELA DAVIS
Entity Type:Organization
Organization Name:PAMELA DAVIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:302-660-2282
Mailing Address - Street 1:1407 SAINT ELIZABETH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-4570
Mailing Address - Country:US
Mailing Address - Phone:302-660-2282
Mailing Address - Fax:302-660-7042
Practice Address - Street 1:5610 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5004
Practice Address - Country:US
Practice Address - Phone:302-660-2282
Practice Address - Fax:302-660-7042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ100011008251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE221487394Medicaid