Healthcare Provider Details

I. General information

NPI: 1124471115
Provider Name (Legal Business Name): PSYCHOTHERAPEUTIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 FOREST ST
DOVER DE
19904-3447
US

IV. Provider business mailing address

983 FOREST ST
DOVER DE
19904-3447
US

V. Phone/Fax

Practice location:
  • Phone: 302-492-7400
  • Fax: 302-736-6004
Mailing address:
  • Phone: 302-492-7400
  • Fax: 302-736-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number1180967
License Number StateDE

VIII. Authorized Official

Name: MR. RANDALL LEWIS COOPER
Title or Position: CFO
Credential:
Phone: 410-778-1099