Provider Demographics
NPI:1568857688
Name:PSYCHOTHERAPEUTIC COMMUNITY SERVICES ASSOC
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC COMMUNITY SERVICES ASSOC
Other - Org Name:PSI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLENDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-810-2465
Mailing Address - Street 1:400 W MAIN ST STE 501
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3295
Mailing Address - Country:US
Mailing Address - Phone:919-530-8888
Mailing Address - Fax:
Practice Address - Street 1:400 W MAIN ST STE 501
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3295
Practice Address - Country:US
Practice Address - Phone:919-530-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:525089072
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-06
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2662-A305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization