Provider Demographics
NPI:1821492646
Name:EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-334-6961
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:29520 CANVASBACK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7124
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:410-822-5569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500301Medicaid
MD609500300Medicaid