Provider Demographics
NPI:1790828598
Name:PSYCHOTHERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
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 1:2260 S CHURCH ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215
Mailing Address - Country:US
Mailing Address - Phone:410-778-9114
Mailing Address - Fax:410-778-7988
Practice Address - Street 1:2260 S. CHURCH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215
Practice Address - Country:US
Practice Address - Phone:336-538-6990
Practice Address - Fax:336-538-6991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300588Medicaid
NC8300588GOtherDIAGNOTIC ASSESSMENT