Provider Demographics
NPI:1760636013
Name:PSYCHOTHERAPEUTIC CHILDREN'S SERVICES
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC CHILDREN'S SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:410-778-9114
Mailing Address - Street 1:870 HIGH STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620
Mailing Address - Country:US
Mailing Address - Phone:410-778-9114
Mailing Address - Fax:410-778-7988
Practice Address - Street 1:630 W DIVISION STREET
Practice Address - Street 2:SUITE F
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904
Practice Address - Country:US
Practice Address - Phone:302-672-7159
Practice Address - Fax:302-672-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE106301261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1427083583Medicaid