1285024810 NPI number — LIFE TRANSFORMATION PSYCHOLOGICAL CENTER, PC

Table of content: (NPI 1285024810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285024810 NPI number — LIFE TRANSFORMATION PSYCHOLOGICAL CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE TRANSFORMATION PSYCHOLOGICAL CENTER, PC
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:
Provider Other Organization Name Type Code:
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:
1285024810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 HERRINGTON RD
Provider Second Line Business Mailing Address:
SUITE C 186
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30044-7217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-530-1504
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 N BROWN RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043-8198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-530-1504
Provider Business Practice Location Address Fax Number:
855-420-6045
Provider Enumeration Date:
02/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
LICENSED CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
706-530-1504

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY003783 , 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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