Basic Information
| Provider Information | |||||||||
| NPI: | 1093164766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PKWY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 HIGH ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216201350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | BURKHARD | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ESPS BILLING SUPERVISOR & CREDENTIA | ||||||||
| AuthorizedOfficialTelephone: | 4103346961 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 609500304 | 05 | MD | MEDICAID |