Basic Information
| Provider Information | |||||||||
| NPI: | 1679616460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPEUTIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2260 S CHURCH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107789114 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Practice Location | |||||||||
| Address1: | 2260 S. CHURCH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107789114 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | CLENDANIEL | ||||||||
| AuthorizedOfficialFirstName: | MARCIA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4108102465 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 8300588 | 05 | NC | MEDICAID | 8300588F | 01 | NC | MOBILE CRISIS MANAGEMENT | OTHER |