Basic Information
| Provider Information | |||||||||
| NPI: | 1235226952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 11120 SOMERSET AVE | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106514200 | ||||||||
| FaxNumber: | 4106514291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | SEIFERT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | KATHYRN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 4103346961 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 259147000 | 01 | MAGELLAN | OTHER | LM49EA | 01 | MD | BCBS GROUP | OTHER | 609550004 | 05 | MD | MEDICAID | 517251 | 01 | UHC MAMSI | OTHER | R968 | 01 | CAREFIRST | OTHER |