Provider Demographics
NPI:1366622110
Name:OVERBROOK THERAPY ASSOCIATES
Entity type:Organization
Organization Name:OVERBROOK THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:215-510-1063
Mailing Address - Street 1:PO BOX 53726
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19105-3726
Mailing Address - Country:US
Mailing Address - Phone:215-510-1063
Mailing Address - Fax:
Practice Address - Street 1:1015 WEST 24TH STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802
Practice Address - Country:US
Practice Address - Phone:302-834-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ10000903251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health