1104255959 NPI number — GEORGIA PEDIATRIC PSYCHOLOGY, INC.

Table of content: (NPI 1104255959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104255959 NPI number — GEORGIA PEDIATRIC PSYCHOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PEDIATRIC PSYCHOLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GPP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104255959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 HAMMOND DR
Provider Second Line Business Mailing Address:
BLDG 1, STE 100
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-999-3477
Provider Business Mailing Address Fax Number:
678-999-3567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 HAMMOND DR
Provider Second Line Business Practice Location Address:
BLDG 1, STE 100
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328-5532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-999-3477
Provider Business Practice Location Address Fax Number:
678-999-3567
Provider Enumeration Date:
11/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
AVITAL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CO-OWNER/CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
678-999-3477

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  3672 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 2999 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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