Basic Information
| Provider Information | |||||||||
| NPI: | 1801155601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PKWY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Practice Location | |||||||||
| Address1: | 11559 SOMERSET AVE | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218531067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | SEIFERT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | KATHRYN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE CEO | ||||||||
| AuthorizedOfficialTelephone: | 4103346961 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LL | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | R968 | 01 | MD | CAREFIRST FEDERAL | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS | OTHER | 520202702 | 05 | MD | MEDICAID |