Provider Demographics
NPI:1487676524
Name:CHESTER RIVER BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:CHESTER RIVER BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:INGRAM
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-778-5550
Mailing Address - Street 1:952 WASHINGTON AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-3322
Mailing Address - Country:US
Mailing Address - Phone:410-778-5550
Mailing Address - Fax:410-778-0984
Practice Address - Street 1:952 WASHINGTON AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-3322
Practice Address - Country:US
Practice Address - Phone:410-778-5550
Practice Address - Fax:410-778-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4278101YP2500X
MDLC6557101YP2500X
MDLC0691101YP2500X
MD01371103T00000X
MD05728103T00000X
MD02027103TC0700X
MD03590103TC2200X
MD025711041C0700X
MD045721041C0700X
MD190331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLT86CHOtherBLUE CROSS LOCAL GROUP #
MDT418OtherBLUE CROSS NAT GROUP #
MDLT86CHOtherBLUE CROSS LOCAL GROUP #