Healthcare Provider Details

I. General information

NPI: 1427083583
Provider Name (Legal Business Name): PSYCHOTHERAPEUTIC COMMUNITY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W DIVISION ST SUITE F
DOVER DE
19904-2760
US

IV. Provider business mailing address

PO BOX 690 SUITE I
CHESTERTOWN MD
21620-0690
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-3366
  • Fax: 302-674-3360
Mailing address:
  • Phone: 410-778-9114
  • Fax: 410-778-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number103TP2701X
License Number StateDE

VIII. Authorized Official

Name: MR. RANDALL COOPER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: C.P.A
Phone: 410-778-9114