| Name: | CSP Psychiatry LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Limited Liability Company |
| Status: | Exists |
| Date of registration: | 08 Oct 2019 (5 years ago) (Companies founded in October 2019) |
| Entity Number: | 000-589-939 |
| Register Number: | 000589939 |
| ZIP code: | 35209 (Companies in Jefferson, 35209) |
| County: | Jefferson |
| Place of Formation: | Jefferson County |
| Registered Office Street Address: | 1711 ROSELAND DRIVEHOMEWOOD, AL 35209 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225672058 | 2019-11-05 | 2019-11-05 | 4505 PINE TREE CIR STE 201, VESTAVIA, AL, 352432380, US | 4505 PINE TREE CIR STE 201, VESTAVIA, AL, 352432380, US | |||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 205-453-4325 |
Authorized person
| Name | KRISTEN AYCOCK |
| Role | BILLER /CREDENTIALING |
| Phone | 2059681227 |
Taxonomy
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 149766 |
| State | AL |
| Issuer | MEDICAID |
| Number | 150612 |
| State | AL |
| Issuer | MEDICAID |
| Number | 150204 |
| State | AL |
| Issuer | MEDICAID |
| Number | 09320028 |
| State | MS |
| Issuer | MEDICAID |
| Number | 149645 |
| State | AL |
| Name | Role |
|---|---|
| PADDOCK, CAYCE | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
