Provider Demographics
NPI:1942343983
Name:PSYCHOTHERAPEUTIC REHABILITATION SERVICES, INC
Entity Type:Organization
Organization Name:PSYCHOTHERAPEUTIC REHABILITATION SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:410-810-2468
Mailing Address - Street 1:870 HIGH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-3914
Mailing Address - Country:US
Mailing Address - Phone:410-778-1099
Mailing Address - Fax:410-778-7988
Practice Address - Street 1:337 BRIGHTSEAT RD STE 106&107
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4736
Practice Address - Country:US
Practice Address - Phone:301-499-6870
Practice Address - Fax:301-499-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589181700Medicaid