Provider Demographics
NPI:1316493000
Name:CHOSEN PSYCHIATRIC SERVICES, LLC
Entity type:Organization
Organization Name:CHOSEN PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VONETTA
Authorized Official - Middle Name:ALETHIA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:410-357-6735
Mailing Address - Street 1:6525 N CHARLES ST
Mailing Address - Street 2:GIBSON BUILDING SUITE 085
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6872
Mailing Address - Country:US
Mailing Address - Phone:410-357-6735
Mailing Address - Fax:410-824-1171
Practice Address - Street 1:6525 N CHARLES ST
Practice Address - Street 2:GIBSON BUILDING SUITE 085
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6872
Practice Address - Country:US
Practice Address - Phone:410-357-6735
Practice Address - Fax:410-824-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR149811363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD086930900Medicaid