Provider Demographics
NPI:1497016562
Name:PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS-CNP
Authorized Official - Phone:605-697-5352
Mailing Address - Street 1:306 4TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-1948
Mailing Address - Country:US
Mailing Address - Phone:605-697-5352
Mailing Address - Fax:605-610-1561
Practice Address - Street 1:306 4TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1948
Practice Address - Country:US
Practice Address - Phone:605-697-5352
Practice Address - Fax:605-610-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000650261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD20110813516668Medicaid