Provider Demographics
NPI:1588689483
Name:PSYCHOGERIATRIC SERVICES LLC
Entity type:Organization
Organization Name:PSYCHOGERIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-691-4952
Mailing Address - Street 1:12073 TECH RD STE B
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7874
Mailing Address - Country:US
Mailing Address - Phone:301-593-1315
Mailing Address - Fax:301-681-4699
Practice Address - Street 1:12073 TECH RD STE B
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7874
Practice Address - Country:US
Practice Address - Phone:301-593-1315
Practice Address - Fax:301-681-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01132OtherMEDICARE
MD400730100Medicaid
MD632MMedicare ID - Type Unspecified