Basic Information
| Provider Information | |||||||||
| NPI: | 1235204355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND , INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANNE ARUNDEL COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 690 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216200690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107789114 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 RESEARCH DR | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107789114 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 4107789114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.