Healthcare Provider Details

I. General information

NPI: 1760636013
Provider Name (Legal Business Name): PSYCHOTHERAPEUTIC CHILDREN'S SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W DIVISION STREET SUITE F
DOVER DE
19904
US

IV. Provider business mailing address

870 HIGH STREET SUITE 2
CHESTERTOWN MD
21620
US

V. Phone/Fax

Practice location:
  • Phone: 302-672-7159
  • Fax: 302-672-7178
Mailing address:
  • Phone: 410-778-9114
  • Fax: 410-778-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number106301
License Number StateDE

VIII. Authorized Official

Name: MR. RANDALL LEWIS COOPER
Title or Position: CFO
Credential: CFO
Phone: 410-778-9114