Provider Demographics
NPI:1003988627
Name:PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC SERVICES OF SOUTHERN MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:410-778-9114
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-0690
Mailing Address - Country:US
Mailing Address - Phone:410-778-9114
Mailing Address - Fax:410-778-7988
Practice Address - Street 1:105 PAUL MELLON CT
Practice Address - Street 2:SUITE 19, 20
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2762
Practice Address - Country:US
Practice Address - Phone:301-638-7787
Practice Address - Fax:301-638-7768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty