Basic Information
Provider Information | |||||||||
NPI: | 1912356684 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2336 GODDARD PKWY | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218011126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: | 4103346362 | ||||||||
Practice Location | |||||||||
Address1: | 315 HIGH ST STE 201 | ||||||||
Address2: |   | ||||||||
City: | CHESTERTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 216201350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2016 | ||||||||
LastUpdateDate: | 09/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURKHARD | ||||||||
AuthorizedOfficialFirstName: | CATHY | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | ESPS BILLING SUPERVISOR & CREDENTIA | ||||||||
AuthorizedOfficialTelephone: | 4103346961 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 520202703 | 05 | MD |   | MEDICAID |