Provider Demographics
NPI:1356484547
Name:PSYCHOTHERAPEUTIC REHABILATION SERVICES
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC REHABILATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
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 1:820 HIGH STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-3909
Mailing Address - Country:US
Mailing Address - Phone:410-778-9114
Mailing Address - Fax:410-778-7988
Practice Address - Street 1:337 BRIGHTSEAT RD
Practice Address - Street 2:SUITE 106 & 107
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4736
Practice Address - Country:US
Practice Address - Phone:301-499-6870
Practice Address - Fax:301-499-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589411500Medicaid
MD653140Medicare UPIN
MD653140Medicare PIN