Healthcare Provider Details

I. General information

NPI: 1720121528
Provider Name (Legal Business Name): PSYCHOTHERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 S CHURCH ST SUITE 304
BURLINGTON NC
21215
US

IV. Provider business mailing address

2260 S. CHURCH ST SUITE 304
BURLINGTON NC
21215
US

V. Phone/Fax

Practice location:
  • Phone: 336-513-4229
  • Fax: 336-513-4228
Mailing address:
  • Phone: 410-778-9114
  • Fax: 410-778-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: MARCIA LYNN CLENDANIEL
Title or Position: BILLING MANAGER
Credential:
Phone: 410-810-2465