Basic Information
| Provider Information | |||||||||
| NPI: | 1588707376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPEUTIC SERVICES, INC | ||||||||
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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: | 3 CENTERVIEW DR | ||||||||
| Address2: | HICKORY BUILDING SUITE 150 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274073725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368349664 | ||||||||
| FaxNumber: | 3368349698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4107789114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8301699 | 05 | NC | MEDICAID | 8301699B | 01 | NC | COMMUNITY SUPPORT SERVICE | OTHER |