Provider Demographics
NPI:1043511173
Name:SAMORAJCZYK PSYCHOLOGICAL SERVICES PA
Entity Type:Organization
Organization Name:SAMORAJCZYK PSYCHOLOGICAL SERVICES PA
Other - Org Name:SAMORAJCZYK PSYCHOLOGICAL SERVICES, INC PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SAMORAJCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-869-1755
Mailing Address - Street 1:19205 SENECA RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3921
Mailing Address - Country:US
Mailing Address - Phone:301-869-1755
Mailing Address - Fax:410-266-5950
Practice Address - Street 1:19205 SENECA RIDGE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-3921
Practice Address - Country:US
Practice Address - Phone:301-869-1755
Practice Address - Fax:410-266-5950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMORAJCZYK PSYCHOLOGICAL SERVICES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00497251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD053380OtherVALUE OPTIONS-BLUE CROSS BLUE SHIELD
MD145425100OtherDEPARTMENT OF LABOR
MD56040001OtherCARE FIRST BLUE CHOICE
MD5604OtherCARE FIRST BLUE CROSS
MD1003988957Medicare UPIN
MD681755Medicare PIN