Basic Information
| Provider Information | |||||||||
| NPI: | 1548348402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1113 HEALTHWAY DRIVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 HEALTHWAY DRIVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | SEIFERT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | KATHYRN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 4103346961 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICE | ||||||||
| 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 | R968 | 01 | DC | CAREFIRST FEDERAL GROUP | OTHER | 609550001 | 05 | MD | MEDICAID | 517251 | 01 | UHC MAMSI GROUP # | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER | 259147000 | 01 | MD | MAGELLAN GROUP | OTHER |