Provider Demographics
NPI:1003021015
Name:SEVERN PSYCHOLOGICAL AND EDUCATION SERVICES INC
Entity Type:Organization
Organization Name:SEVERN PSYCHOLOGICAL AND EDUCATION SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMBATZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-269-7789
Mailing Address - Street 1:353 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-1433
Mailing Address - Country:US
Mailing Address - Phone:410-298-8223
Mailing Address - Fax:410-298-8225
Practice Address - Street 1:353 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:RIVA
Practice Address - State:MD
Practice Address - Zip Code:21140-1433
Practice Address - Country:US
Practice Address - Phone:410-298-8223
Practice Address - Fax:410-298-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-12
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1872103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD136641600Medicaid
MD136641600Medicaid