Provider Demographics
NPI:1366999310
Name:PSI ACIST PROGRAM
Entity type:Organization
Organization Name:PSI ACIST PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLENDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-810-2465
Mailing Address - Street 1:983 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3447
Mailing Address - Country:US
Mailing Address - Phone:302-480-9590
Mailing Address - Fax:302-480-9591
Practice Address - Street 1:983 FOREST ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3447
Practice Address - Country:US
Practice Address - Phone:302-480-9590
Practice Address - Fax:302-480-9591
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCHOTHERAPEUTIC SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-07
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1990037507251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health