Provider Demographics
NPI:1609316272
Name:DELMAR GLEN PACK PA
Entity Type:Organization
Organization Name:DELMAR GLEN PACK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-366-2700
Mailing Address - Street 1:810 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 BRIARWOOD CT
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-4319
Practice Address - Country:US
Practice Address - Phone:386-956-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6914103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty