Provider Demographics
NPI:1982319810
Name:EASTERN SHORE THERAPY, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RONNIE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-275-1961
Mailing Address - Street 1:1046 POND NECK RD
Mailing Address - Street 2:
Mailing Address - City:EARLEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21919-2342
Mailing Address - Country:US
Mailing Address - Phone:410-275-1961
Mailing Address - Fax:
Practice Address - Street 1:1046 POND NECK RD
Practice Address - Street 2:
Practice Address - City:EARLEVILLE
Practice Address - State:MD
Practice Address - Zip Code:21919-2342
Practice Address - Country:US
Practice Address - Phone:410-275-1961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty