Provider Demographics
NPI:1386717189
Name:EASTERN SHORE PSYCHOLOGICAL SERVICE
Entity type:Organization
Organization Name:EASTERN SHORE PSYCHOLOGICAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHYRN
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-334-6961
Mailing Address - Street 1:1113 HEALTHWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:1113 HEALTHWAY DRIVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN SHORE PSYCHOLOGICAL SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500300Medicaid
517251OtherUHC MAMSI GROUP
MDLM49EAOtherCAREFIRST BCBS GROUP
DCR968OtherCAREFIRST FEDERAL GROUP
MD742LMedicare PIN
MD609500300Medicaid