Basic Information
| Provider Information | |||||||||
| NPI: | 1427083583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPEUTIC COMMUNITY SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 690 | ||||||||
| Address2: | SUITE I | ||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216200690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107789114 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 W DIVISION ST | ||||||||
| Address2: | SUITE F | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199042760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026743366 | ||||||||
| FaxNumber: | 3026743360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4107789114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | C.P.A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | 103TP2701X | DE | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
ID Information
| ID | Type | State | Issuer | Description | 0000930161 | 05 | DE | MEDICAID |