Provider Demographics
NPI:1093074064
Name:EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-334-6961
Mailing Address - Street 1:1113 HEALTHWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:1113 HEALTHWAY DRIVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6362
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLM49EAOtherCAREFIRST BCBS
MDR968OtherCAREFIRST FEDERAL
MD520202700Medicaid