Provider Demographics
NPI:1356613491
Name:PENINSULA CONSULTING SERVICES, INC.
Entity type:Organization
Organization Name:PENINSULA CONSULTING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYANTHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-859-8699
Mailing Address - Street 1:104 WILLIAMSPORT CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6400
Mailing Address - Country:US
Mailing Address - Phone:443-859-8699
Mailing Address - Fax:443-859-8747
Practice Address - Street 1:104 WILLIAMSPORT CIR
Practice Address - Street 2:SUITE C
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6400
Practice Address - Country:US
Practice Address - Phone:443-859-8699
Practice Address - Fax:443-859-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD131171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty