1811030612 NPI number — PSYCHOTHERPEUTIC SERVICES, INC

Table of content: (NPI 1811030612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811030612 NPI number — PSYCHOTHERPEUTIC SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOTHERPEUTIC SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811030612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21620-0690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-778-9114
Provider Business Mailing Address Fax Number:
410-778-7988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 RUDD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27217-2957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-513-4229
Provider Business Practice Location Address Fax Number:
336-513-4228
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
410-778-9114

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8300589 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300589B . This is a "COMMUNITY SUPPORT SERVICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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