1477613578 NPI number — PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND

Table of content: (NPI 1477613578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477613578 NPI number — PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND
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:
6
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:
1477613578
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:
337 BRIGHTSEAT RD
Provider Second Line Business Practice Location Address:
SUTIE 106 AND 107
Provider Business Practice Location Address City Name:
LANDOVER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20785-4736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-499-1474
Provider Business Practice Location Address Fax Number:
301-499-0145
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 103TP2701X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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