Provider Demographics
NPI:1487982880
Name:SELF REALIZATION, LLC
Entity type:Organization
Organization Name:SELF REALIZATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:EDD
Authorized Official - Phone:302-312-8221
Mailing Address - Street 1:9 MORNING DEW DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-2419
Mailing Address - Country:US
Mailing Address - Phone:302-312-8221
Mailing Address - Fax:
Practice Address - Street 1:102 SLEEPY HOLLOW DR
Practice Address - Street 2:STE 200
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5841
Practice Address - Country:US
Practice Address - Phone:302-312-8221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000757103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty