Healthcare Provider Details

I. General information

NPI: 1629108261
Provider Name (Legal Business Name): PARK PLACE PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WINTON M. BLOUNT LOOP
MONTGOMERY AL
36117
US

IV. Provider business mailing address

P.O. BOX 241486
MONTGOMERY AL
36124-1486
US

V. Phone/Fax

Practice location:
  • Phone: 334-356-1417
  • Fax: 334-356-1433
Mailing address:
  • Phone: 334-356-1417
  • Fax: 334-356-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2914
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1452
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2914
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0421
License Number StateAL

VIII. Authorized Official

Name: MR. DAVID D. SCHAFTER
Title or Position: OWNER
Credential: D.O., PH.D.
Phone: 334-356-1417