Provider Demographics
NPI:1952646705
Name:DEVEREUX
Entity Type:Organization
Organization Name:DEVEREUX
Other - Org Name:DEVEREUX NEW JERSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT DIRECTOR
Authorized Official - Prefix:MRS
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 1:2012 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:286 MANTUA GROVE RD
Practice Address - Street 2:BLDG #4
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08066-1738
Practice Address - Country:US
Practice Address - Phone:856-599-6429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities