Basic Information
| Provider Information | |||||||||
| NPI: | 1942343983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPEUTIC RESIDENTIAL SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 870 HIGH ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216203914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107781099 | ||||||||
| FaxNumber: | 4107787988 | ||||||||
| Practice Location | |||||||||
| Address1: | 337 BRIGHTSEAT RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | LANDOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207854736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014996870 | ||||||||
| FaxNumber: | 3014991448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4108102468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 589181700 | 05 | MD | MEDICAID |