Basic Information
Provider Information | |||||||||
NPI: | 1730252537 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 4106514290 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 08/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SEIFERT | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | KATHYRN | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR CEO | ||||||||
AuthorizedOfficialTelephone: | 4103346961 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICE, LLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | MD | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 259147000 | 01 | MD | MAGELLAN GROUP | OTHER | 609500303 | 05 | MD |   | MEDICAID | R968 | 01 | DC | CAREFIRST FEDERAL GROUP | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER | 517251 | 01 |   | UHC MAMSI GROUP | OTHER |